Value of diffusion kurtosis MR imaging and conventional diffusion weighed imaging for evaluating response to first-line chemotherapy in unresectable pancreatic cancer

OBJECTIVE

To investigate the diagnostic value of diffusion kurtosis magnetic resonance imaging (DKI) and conventional diffusion-weighted imaging (DWI) for evaluating the response to first-line chemotherapy in unresectable pancreatic cancer.

MATERIALS AND METHODS

We retrospectively analyzed 21 patients with clinically and pathologically confirmed unresected pancreatic cancer who received palliative chemotherapy. Three-tesla MRI examinations containing DWI sequences with b values of 0, 100, 700, 1400, and 2100 s/mm2 were performed before and after chemotherapy. Parameters included the apparent diffusion coefficient (ADC), mean diffusion coefficient (MD), and mean diffusional kurtosis (MK). The performances of the DWI and DKI parameters in distinguishing the response to chemotherapy were evaluated by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. Overall survival (OS) was calculated from the date of first treatment to the date of death or the latest follow-up date.

RESULTS

The ADCchange and MDchange were significantly higher in the responding group (PR group) than in the nonresponding group (non-PR group) (ADCchange: 0.21 ± 0.05 vs. 0.11 ± 0.09, P = 0.02; MDchange: 0.37 ± 0.24 vs. 0.10 ± 0.12, P = 0.002). No statistical significance was shown when comparing ADCpre, ADCpost, MKpre, MKpost, MKchange, MDpre, and MDpost between the PR and non-PR groups. The ROC curve analysis indicated that MDchange (AUC = 0.898, cutoff value = 0.7143) performed better than ADCchange (AUC = 0.806, cutoff value = 0.1369) in predicting the response to chemotherapy.

CONCLUSION

The ADCchange and MDchange demonstrated strong potential for evaluating the response to chemotherapy in unresectable pancreatic cancer. The MDchange showed higher specificity in the classification of PR and non-PR than the ADCchange. Other parameters, including ADCpre, ADCpost, MKpre, MKpost, MKchange, MDpre, and MDpost, are not suitable for response evaluation. The combined model SUMchange demonstrated superior performance compared to the individual DWI and DKI models. Further experiments are needed to evaluate the potential of DWI and DKI parameters in predicting the prognosis of patients with unresectable pancreatic cancer.

Gastrojejunostomy versus endoscopic duodenal stent placement for gastric outlet obstruction in patients with unresectable pancreatic cancer: a propensity score-matched analysis

BACKGROUND

Treatments for patients with gastric outlet obstruction (GOO) due to unresectable pancreatic cancers (URPC) include gastrojejunostomy (GJJ) and endoscopic duodenal stent placement (EDSP). This study compared the efficacy and safety of GJJ and EDSP in patients with GOO due to URPC.

METHODS

This study retrospectively evaluated consecutive patients with GOO due to URPC who underwent GJJ or EDSP between April 2016 and March 2020. The efficacy and safety of GJJ and EDSP were compared with propensity score analysis. Subgroup analyses of overall survival (OS) were compared after propensity matching.

RESULTS

Data were obtained from 54 patients who underwent GJJ and from 73 who underwent EDSP at five tertiary care hospitals. After propensity matching, OS was significantly longer in patients who underwent GJJ than EDSP (110 vs. 63 days, respectively; p = 0.019). Evaluation of long-term adverse events showed that the frequency of cholangitis and obstructive jaundice was significantly lower in the matched GJJ than in the matched EDSP group (p = 0.012). Subgroup analyses showed that OS in patients with good performance status (PS; p = 0.041), biliary obstruction (p = 0.007), and duodenal obstruction near the papilla (p = 0.027), and those receiving chemotherapy (p = 0.010), was significantly longer in the matched GJJ group than in matched EDSP group.

CONCLUSION

GJJ provides longer OS than EDSP for patients with GOO caused by URPC, especially for patients with good PS, biliary obstruction, and duodenal obstruction near the papilla, and those receiving chemotherapy.

Normalization of tumor markers and a clear resection margin affect progression-free survival of patients with unresectable pancreatic cancer who have undergone conversion surgery

BACKGROUND

With the advent of intensive combination regimens, an increasing number of patients with unresectable pancreatic cancer (UPC) have regained the opportunity for surgery. We investigated the clinical benefits and prognostic factors of conversion surgery (CS) in UPC patients.

METHODS

We retrospectively enrolled patients with UPC who had received CS following first-line systemic treatment in our center between 2014 to 2022. Treatment response, safety of the surgical procedure and clinicopathological data were collected. We analyzed the prognostic factors for postoperative survival among UPC patients who had CS.

RESULTS

Sixty-seven patients with UPC were enrolled (53 with locally advanced pancreatic cancer (LAPC) and 14 with metastatic pancreatic cancer (MPC)). The duration of preoperative systemic treatment was 4.17 months for LAPC patients and 6.52 months for MPC patients. All patients experienced a partial response (PR) or had stable disease (SD) preoperatively according to imaging. Tumor resection was unsuccessful in four patients and, finally, R0 resection was obtained in 81% of cases. Downstaging was determined pathologically in 87% of cases; four patients achieved a complete pathological response. Median postoperative-progression-free survival (PO-PFS) was 9.77 months and postoperative overall survival (PO-OS) was 31.2 months. Multivariate logistic regression analyses revealed that the resection margin and postoperative changes in levels of tumor markers were significant prognostic factors for PO-PFS. No factors were associated significantly with PO-OS according to multivariate analyses.

CONCLUSIONS

CS is a promising strategy for improving the prognosis of UPC patients. The resection margin and postoperative change in levels of tumor markers are the most important prognostic factors for prolonged PFS. Multidisciplinary treatment in high-volume centers is strongly recommended. Prospective studies must be undertaken to resolve the various problems regarding optimal regimens, the duration of treatment, and detailed criteria for CS.

STNM01, the RNA oligonucleotide targeting carbohydrate sulfotransferase 15, as second-line therapy for chemotherapy-refractory patients with unresectable pancreatic cancer: An open label, phase I/IIa trial

BACKGROUND

The impact of stroma-targeting therapy on tumor immune suppression is largely unexplored. An RNA oligonucleotide, STNM01, has been shown to repress carbohydrate sulfotransferase 15 (CHST15) responsible for tumor proteoglycan synthesis and matrix remodeling. This phase I/IIa study aimed to evaluate the safety and efficacy of STNM01 in patients with unresectable pancreatic ductal adenocarcinoma (PDAC).

METHODS

This was an open-label, dose-escalation study of STNM01 as second-line therapy in gemcitabine plus nab-paclitaxel-refractory PDAC. A cycle comprised three 2-weekly endoscopic ultrasound-guided locoregional injections of STNM01 at doses of 250, 1,000, 2,500, or 10,000 nM in combination with S-1 (80-120 mg twice a day for 14 days every 3 weeks). The primary outcome was the incidence of dose-liming toxicity (DLT). The secondary outcomes included overall survival (OS), tumor response, changes in tumor microenvironment on immunohistopathology, and safety (jRCT2031190055).

FINDINGS

A total of 22 patients were enrolled, and 3 cycles were repeated at maximum; no DLT was observed. The median OS was 7.8 months. The disease control rate was 77.3%; 1 patient showed complete disappearance of visible lesions in the pancreas and tumor-draining lymph nodes. Higher tumoral CHST15 expression was associated with poor CD3⁺ and CD8⁺ T cell infiltration at baseline. STNM01 led to a significant reduction in CHST15, and increased tumor-infiltrating CD3⁺ and CD8⁺ T cells in combination with S-1 at the end of cycle 1. Higher fold increase in CD3⁺ T cells correlated with longer OS. There were 8 grade 3 adverse events.

INTERPRETATION

Locoregional injection of STNM01 was well tolerated in patients with unresectable PDAC as combined second-line therapy. It prolonged survival by enhancing T cell infiltration in tumor microenvironment.

FUNDING

The present study was supported by the Japan Agency for Medical Research and Development (AMED).

A case of pathological complete response with liposomal irinotecan + 5-FU/LV for unresectable locally advanced pancreatic cancer

Background

Pancreatic cancer has one of the worst prognoses of any all cancers. 5-FU/leucovorin + irinotecan + oxaliplatin (FOLFIRINOX), gemcitabine (GEM) plus nab-paclitaxel regimens have been recognized as global-standard, first-line treatments for patients with advanced pancreatic cancer. The liposomal irinotecan (nal-IRI) + 5-FU/LV regimen is now included in treatment guidelines as a recommended and approved option for use in patients with metastatic pancreatic cancer that has progressed after GEM-based therapy and who have a suitable performance status and comorbidity profile. There is no report that nal-IRI + 5-FU/LV regimen was significantly effective, and we will report it because we experienced this time.

Case presentation

A 69-year-old man presented with epigastric pain, and a contrast computed tomography (CT) revealed an enhanced mass lesion measuring 33 × 27 mm on the pancreatic body with encasement of the common hepatic artery (CHA) and the splenic vein. An endoscopic ultrasound-guided fine needle aspiration was performed and demonstrated cytology consistent with adenocarcinoma. Therefore, we diagnosed the patient with unresectable locally advanced pancreatic cancer. The patient received the GEM and S-1 regimen; however, the adverse event was relatively severe. Then, 11 cycles of nal-IRI + 5-FU/LV regimen were administered. A CT scan revealed that the tumor had shrunk to 18 × 7 mm in diameter with encasement of the CHA. The encasement of the splenic vein had disappeared, without any distant metastases. From this post-chemotherapy evaluation and intraoperative frozen section of around the celiac artery, gastroduodenal artery and pancreas stump confirmed absence of tumor cells, we performed distal pancreatectomy with celiac axis resection. A histological examination of the surgical specimen revealed no evidence of residual adenocarcinoma, consistent with a pathological complete response to treatment.

Conclusions

We present the first case of a pathological complete response with nal-IRI + 5-FU/LV for unresectable, locally advanced pancreatic cancer. In the future, nal-IRI may become a key drug for pancreatic cancer treatment.

Protein intake after the initiation of chemotherapy is an independent prognostic factor for overall survival in patients with unresectable pancreatic cancer: A prospective cohort study

BACKGROUND & AIMS

This study was conducted to investigate the nutritional status and longitudinal dietary intake during the course of chemotherapy, and their relationships with the survival in patients with unresectable pancreatic cancer.

METHODS

A prospective cohort study was conducted in 38 patients with unresectable pancreatic cancer receiving chemotherapy between January 2018 and November 2019. Subjective global assessment was used to assess the nutritional status, and the dietary intake was assessed monthly, for up to 12 months, using a brief self-administered diet history questionnaire. The primary outcome was overall survival, and the secondary outcome was progression-free survival. Cox regression analysis was performed to identify independent prognostic factors.

RESULTS

Moderate or severe malnutrition was found in 34.2% of the participants. Daily protein intake was significantly higher in the survivor group than in the deceased group at one month after the initiation of chemotherapy (1.4 ± 0.7 g/kg/day vs. 0.9 ± 0.5 g/kg/day, p = 0.019), while the baseline nutritional intakes were similar between the two groups. Univariate analysis identified weight loss >3.5%, energy intake <25 kcal/kg/day, protein intake <1.1 g/kg/day, and malnutrition as possible poor prognostic factors. Multivariate analysis identified protein intake <1.1 g/kg/day (hazard ratio [HR]: 9.03, 95%CI: 1.45-56.32, p = 0.018) as an independent poor prognostic factor.

CONCLUSIONS

Insufficient protein intake was identified as an independent poor prognostic factor in patients with unresectable pancreatic cancer receiving chemotherapy. Improving the dietary protein intake could be a useful therapeutic approach in patients with advanced pancreatic cancer receiving chemotherapy.

Phase 1 study of Gemcitabine/Nab-paclitaxel/S-1 in patients with unresectable pancreatic cancer (GeNeS1S trial)

PURPOSE

We conducted a phase 1 study to determine the maximum tolerated dose and the recommended dose of gemcitabine/nab-paclitaxel/S-1 combination chemotherapy in patients with unresectable pancreatic cancer.

METHODS

We enrolled patients aged 20 years or older with unresectable pancreatic cancer and who had not been treated with chemotherapy or radiation therapy. Gemcitabine and nab-paclitaxel were administered on days 1 and 8, and S-1 was administered orally twice daily for 2 weeks, repeated every 3 weeks. The starting dose was level 0 [gemcitabine 700 mg/m², nab-paclitaxel 90 mg/m², S-1 60/80/100 mg/day (< 1.25 m²/1.25-1.50 m²/ > 1.5 m²)]. Dose-limiting toxicities were determined during the first course, and a classical 3 + 3 dose finding design was planned.

RESULTS

From March 2018 to October 2019, 20 patients were enrolled. At dose level 0, three of six patients experienced dose-limiting toxicities; one grade 3 skin rash on day 8, and two grade 3 or 4 neutropenia on day 8. At dose level-1 (gemcitabine 600 mg/m², nab-paclitaxel 90 mg/m², and S-1 50/70/80 mg/day), two of twelve patients experienced dose-limiting toxicities, all of which were grade 3 neutropenia on day 8. The most frequently observed toxicity during eight courses was neutropenia. Other treatment-related adverse events were mild. Eleven out of 19 (58%) patients achieved partial response.

CONCLUSION

We defined the maximum tolerated dose and the recommended dose for combination therapy with gemcitabine/nab-paclitaxel/S-1 as dose level-1. Considering the observed response rate, further studies are warranted in order to determine the efficacy of this regimen (UMIN-CTR 000030007).

A Case of Pathological Complete Response Following FOLFIRINOX Therapy for Pancreatic Adenocarcinoma with Synchronous Distant Lymph Node Metastases

INTRODUCTION

We report a case of conversion surgery for pancreatic ductal adenocarcinoma (PDAC) with synchronous distant metastases showing pathological complete response (pCR) after FOLFIRINOX therapy.

PRESENTATION OF CASE

A 46-year-old woman with obstructive jaundice was referred to our hospital. A CT scan revealed a hypo-vascular mass in the head of the pancreas with multiple para-aortic lymph nodes and a Virchow's node swollen. The serum CA 19-9 level was 71795.1 U/mL. The result of tumor biopsy from the biliary stenotic site was concordant with adenocarcinoma. She was diagnosed with PDAC with distant metastases. After 10 courses of FOLFIRINOX followed by 4 courses of FOLFIRI, a CT scan showed that distant lymph node swellings disappeared, and CA19-9 level became almost normal. She underwent pancreaticoduodenectomy with dissection of para-aortic lymph nodes 8 months after the initiation of chemotherapy. Pathologically, no evidence of residual adenocarcinoma was observed in neither pancreas nor lymph nodes. Adjuvant chemotherapy using S-1 was administered for 6 months, and no recurrence has been observed 4 years after surgery. BRCA1/2 mutations were not detected in patient's DNA.

DISCUSSION

With the induction of intensive chemotherapies such as FOLFIRINOX, an increasing number of patients with synchronous distant metastases could become suitable candidates for surgery of the primary lesion because of the potential complete response of metastatic lesions.

CONCLUSION

This case presented a rare occurrence of pCR in a patient with unresectable PDAC with distant metastases who received FOLFIRINOX. The feasibility and benefits of conversion surgery in such patients must be investigated in future trials.

Radiation therapy for patients with locally advanced pancreatic cancer: Evolving techniques and treatment strategies

Despite ongoing efforts, patients with locally advanced pancreatic cancer (LAPC) continue to have a dismal prognosis. Such tumors are unresectable, and optimal treatment with chemotherapy and/or radiation therapy is still not established. While chemotherapy is conventionally aimed at preventing metastatic spread of disease, radiation therapy acts locally, improving local control which can potentially improve overall survival and most importantly quality of life. Here, we aim to review the primary literature assessing the role of diverse radiation therapy strategies for patients with LAPC. Many radiation regimens can be considered, and no standard treatment has demonstrated a clear improvement in clinical outcomes. We advise that the modality of choice be dependent on the availability of equipment, the dose and fractionation of treatment, as well as the dose received by normal tissue. Moreover, a candid discussion with the patient concerning treatment goals is equally as essential. Three notable strategies for LAPC are intensity-modulated radiation therapy, volumetric modulated arc therapy, and proton. These radiation modalities tend to have improved dose distribution to the target volumes, while minimizing the radiation dose to surrounding normal tissues. Stereotactic body radiation therapy can also be considered in LAPC patients in cases where the tumor does not invade the duodenum or other neighboring structures. Because of the high doses delivered by stereotactic body radiation therapy, proper respiratory and tumor motion management should be implemented to reduce collateral radiation dosing. Despite improved clinical outcomes with modern radiation modalities, evolving techniques, and more accurate planning, future studies remain essential to elucidate the optimal role for radiation therapy among patients with LAPC.

Proposal of predictive model on survival in unresectable pancreatic cancer receiving systemic chemotherapy

Aims: To construct a predictive model for overall survival (OS) in unresectable pancreatic cancer (PaC) undergoing systemic chemotherapy and to confirm its accuracy in an independent cohort. Patients and methods: The training set (Ts) and the validation set (Vs) included 93 patients (median age=71 years) and 75 patients (median age=76 years). In the Ts, we examined variables linked to OS by uni- and multivariate analyses and constructed a predictive model for OS. Next, we evaluated the reproducibility of the proposed model in the Vs. Results: In the multivariate analysis for the Ts, PaC stage IV (P=0.0020) and carbohydrate antigen (CA) 19-9 ≥437.5 IU/l (P=0.0237) were identified to be significant factors associated with OS. Patients with PaC stage IV or not were given a score of 1 or 0, whereas patients with CA19-9 ≥437.5 IU/l or <437.5 IU/l were given a score of 1 or 0. Sum of the point of PaC stage (0 or 1) and CA19-9 (0 or 1) was defined as "PaC-CA score". In the Ts, there were 16 patients with score 0, 40 with score 1 and 37 with score 2, while in the Vs, there were 9 patients with score 0, 32 with score 1 and 34 with score 2. Overall P values reached significance in the Ts (P=0.0002), the Vs (P=0.0029) and the combined Ts and Vs (P<0.0001) among patients with PaC score 0, 1 and 2. Conclusion: PaC-CA score can be helpful for risk stratification in PaC patients undergoing systemic chemotherapy.

Conversion surgery for initially unresectable pancreatic cancer: current status and unresolved issues

Pancreatic cancer is one of the most lethal of all malignancies. One of the reasons for the dismal prognosis is that most diagnoses are made when the disease is either locally advanced or metastatic. Recent advances in chemotherapy and chemoradiotherapy (CRT) enable "conversion surgery" to be performed for selected patients with initially unresectable pancreatic cancer following favorable responses to preoperative treatment. Using FOLFIRINOX as preoperative treatment, the resection rate was reported as 6-44% of patients with locally advanced cancer and the prognosis of these patients was favorable. Even for metastasized cancer, recent reports show the effectiveness of conversion surgery, which has achieved 27-56 months of median overall survival. However, there are many unanswered questions about conversion surgery. The optimal regimen and duration of preoperative treatment remain unclear and there is still debate regarding the safety and effectiveness of vascular resection, which is often required for curative resection of locally advanced cancer. Accumulation of more data on conversion surgery is required to establish the safety and effectiveness of this treatment. In this review, we summarize the current status and unresolved issues about conversion surgery for initially unresectable pancreatic cancer.

Conversion surgery only for highly selected patients with unresectable pancreatic cancer: a satisfactory outcome in exchange for a lower resection rate

PURPOSE

The purpose of this study is to clarify the resection rate, safety, and significance of conversion surgery for highly selected patients with unresectable pancreatic cancer (URPca).

METHODS

We studied 434 URPca patients. Conversion surgery was permitted only for patients who met following requirements: responders to first-line therapy, showing sufficient reduction of the local tumor to enable complete resection, at least 6 months of disease control, and no metastatic lesions detected on radiological examinations (for patients with metastatic disease). The overall survival (OS) was compared between patients who underwent surgery and those who did not. Furthermore, a multivariate analysis was performed to identify possible predictive factors for both total patients with URPca and responders.

RESULTS

Conversion surgery was performed in 18 patients (4.1%). The pathologically complete resection rate was 88.9% (16/18). The median operative time, blood loss, and hospitalization duration were 450 min, 780 ml, and 29 days, respectively. The OS was significantly better in patients who underwent surgery than in those who did not. In a multivariate analysis, conversion surgery was shown to be significantly correlated with the OS both in total patients and responders.

CONCLUSIONS

A satisfactory outcome was achieved for highly selected patients with URPca in exchange for a lower resection rate (4.1%).

Survival benefit of conversion surgery for patients with initially unresectable pancreatic cancer who responded favorably to nonsurgical treatment

BACKGROUND

Conversion surgery (CS) is expected as a new therapeutic strategy for patients with unresectable pancreatic cancer (UR-PC). We analyzed outcomes of CS for patients with UR-PC and evaluated the survival benefit of CS.

METHODS

Thirty-four patients diagnosed with UR-PC according to the National Comprehensive Cancer Network guideline underwent CS in our hospital. Resectability was considered by multimodal images in patients who underwent nonsurgical treatment (NST) for more than 6 months. CS was performed only in patients who were judged to be able to undergo R0 resection.

RESULTS

Twenty-six patients had locally advanced PC, and eight had distant metastases. The median duration of NST was 9 (range 5-44) months. R0 resection was achieved in 30 patients (88.2%). Six patients (17.6%) showed Evans grade ≥III. Three- and 5-year overall survival (OS) rates from initial treatment were 74% and 56.9%, respectively, with median survival time (MST) of 5.3 years. The actual 5-year OS rate in 19 patients was 47.4% with an MST of 4.0 years. Patients with Evans grade ≥III had a better prognosis than those with Evans grade <III (P = 0.0092, log-rank test).

CONCLUSIONS

Conversion surgery might have survival benefits to patients with UR-PC who responded favorably to NST.

Technique, safety, and feasibility of EUS-guided radiofrequency ablation in unresectable pancreatic cancer

BACKGROUND AND AIMS

Radiofrequency ablation (RFA) is a well-recognized local ablative technique applied in the treatment of different solid tumors. Intraoperative RFA has been used for non-metastatic unresectable pancreatic ductal adenocarcinoma (PDAC), showing increased overall survival in retrospective studies. A novel RFA probe has recently been developed, allowing RFA under endoscopic ultrasound (EUS) guidance. Aim of the present study was to assess the feasibility and safety of EUS-guided RFA for unresectable PDACs.

METHODS

Patients with unresectable non-metastatic PDAC were included in the study following neoadjuvant chemotherapy. EUS-guided RFA was performed using a novel monopolar 18-gauge electrode with a sharp conical 1 cm tip for energy delivery. Pre- and post-procedural clinical and radiological data were prospectively collected.

RESULTS

Ten consecutive patients with unresectable PDAC were enrolled. The procedure was successful in all cases and no major adverse events were observed. A delineated hypodense ablated area within the tumor was observed at the 30-day CT scan in all cases.

CONCLUSIONS

EUS-guided RFA is a feasible and safe minimally invasive procedure for patients with unresectable PDAC. Further studies are warranted to demonstrate the impact of EUS-guided RFA on disease progression and overall survival.

Impact of the treatment of pancreatic exocrine insufficiency on survival of patients with unresectable pancreatic cancer: a retrospective analysis

BACKGROUND

Malnutrition and weight loss are commonly observed in patients with pancreatic cancer and contribute to poor survival. Pancreatic exocrine insufficiency (PEI), which can be caused by ductal obstruction by a tumor, causes maldigestion and malabsorption of nutrients, thus contributing to malnutrition in these patients. In this study, we evaluated the effects of pancreatic enzyme replacement therapy (PERT) on survival in patients with unresectable pancreatic cancer.

METHODS

A retrospective analysis was conducted on a database of patients with unresectable, pathologically confirmed pancreatic cancer. All patients were evaluated for palliative chemotherapy and received the optimal palliative care. Patients were divided into two groups: Group 1 received standard therapy; Group 2 underwent additional evaluation of the pancreatic function and therapy with PERT, if needed. Survival (median and 95% confidence interval [CI]) was analyzed using Kaplan-Meier and Cox regression; groups were compared using the log-rank test.

RESULTS

Overall, 160 patients with unresectable pancreatic cancer were included in the analysis (mean age: 70.5 years [range 28-100]; gender: 57.5% male; tumor stage: 78.7% Stage IV). Eighty-six patients (53.75%) were in Group 1 and 74 (46.25%) were in Group 2. Age, gender, tumor size, location and stage, weight loss, and serum CA 19-9 were similar between groups. Ninety-three (58.1%) patients received palliative chemotherapy; 46.5% in Group 1 and 71.6% in Group 2 (P < 0.001). Forty-nine (66.2%) patients in Group 2 and none in Group 1 received PERT. Survival in Group 2 (189 days, 95% CI 167.0-211.0 days) was significantly longer than in Group 1 (95.0 days, 95% CI 75.4-114.6 days) (HR 2.117, 95% CI 1.493-3.002; P < 0.001). Chemotherapy and PERT were significantly and independently associated with longer survival in a model controlled by age and tumor stage. In patients with significant weight loss at diagnosis (> 10% bodyweight within 6 months), PERT was associated with longer survival (HR 2.52, 95% CI 1.55-4.11; P < 0.001).

CONCLUSIONS

In patients with unresectable pancreatic cancer, PERT in patients with PEI was associated with longer survival compared with those not receiving PERT, especially in those experiencing significant weight loss. This finding should guide future prospective clinical trials of similar interventions.

Multicenter, randomized, open-label Phase II study comparing S-1 alternate-day oral therapy with the standard daily regimen as a first-line treatment in patients with unresectable advanced pancreatic cancer

PURPOSE

Non-inferiority for overall survival (OS) following alternate-day treatment with the oral anticancer drug S-1 compared with standard daily treatment was assessed in Japanese patients with unresectable advanced pancreatic cancer in a multicenter, randomized, phase II study. This trial was registered at the UMIN Clinical Trials Registry (no. 000008604).

METHODS

Chemotherapy-naïve patients with locally advanced or metastatic pancreatic cancer were randomly assigned 2:1 to treatment with alternate-day (twice daily on alternate days from days 1 through 42 of a 42-day cycle) or daily (twice daily on days 1 through 28 of a 42-day cycle) treatment with S-1. The primary endpoint was OS. Secondary endpoints were progression-free survival (PFS), time to treatment failure, response rate, quality of life assessments, and safety.

RESULTS

A total of 190 patients were enrolled, of which 185 were included in the final analysis (alternate-day: 121; daily: 64). Median OS was 9.4 for the alternate-day group and 10.4 months for the daily group [hazard ratio (HR), 1.19; 95% credible interval, 0.86 to 1.64], indicating that non-inferiority of alternate-day treatment to daily treatment was not demonstrated. Median PFS was 3.0 for the alternate-day group and 4.2 months for the daily group (HR, 1.65; 95% credible interval, 1.20-2.29). The incidence of anorexia, fatigue, neutrophils, pigmentation, and pneumonitis was lower in alternate-day treatment compared with daily treatment.

CONCLUSION

S-1 for advanced pancreatic cancer should be taken daily as recommended, based on the decreased OS and PFS and marginal improvement in safety observed in the alternate-day group.

Radical resection of a primarily unresectable pancreatic cancer after neoadjuvant chemotherapy using gemcitabine, ts-1, and nafamostat mesilate; report of a case. Int Surg. 2015;100:287-291. [PMID: 25692432 DOI: 10.9738/INTSURG-D-13-00193.1]

A 58-year-old male visited his primary physician for epigastric and back pain. Abdominal-enhanced computed tomography (CT) revealed a hypovascular pancreatic tumor measuring 17 × 11 mm in the uncinate process of the pancreas extending into the superior mesenteric plexus for greater than 180°. With a diagnosis of unresectable pancreatic cancer, the patient received gemcitabine and TS-1 with arterial infusion of nafamostat mesilate. After 3 courses of chemotherapy, enhanced CT revealed a decrease in size of the pancreatic tumor with no lymph node and distant metastasis and improved invasion of the superior mesenteric plexus down to 120°. The patient underwent R0 pancreaticoduodenectomy. The patient made a satisfactory recovery without complications and was discharged on postoperative day 10. We herein report the first curative resected case of a primarily unresectable pancreatic cancer after neoadjuvant chemotherapy using gemcitabine, TS-1, and nafamostat mesilate.

Chemotherapy-induced neutropenia as a prognostic factor in patients with unresectable pancreatic cancer

PURPOSE

We conducted a retrospective cohort study to examine whether neutropenia could be an indicator of good prognosis in patients treated with gemcitabine (GEM) for unresectable pancreatic cancer.

METHODS

A total of 178 patients with unresectable pancreatic cancer, who were treated with first-line (n = 121) or second-line (n = 57) GEM, were included in our analyses. A Cox proportional hazard model was used to examine the effect of the grade of GEM-induced neutropenia on prognosis. Furthermore, the difference in survival time for each grade was assessed using a log-rank test.

RESULTS

In the first-line population, the hazard ratios of patients with grade 2 or grade 3 neutropenia compared with the ratios of those without neutropenia (grade 0) were 0.43 (95% CI 0.27-0.70) and 0.37 (0.21-0.65), respectively (p < 0.05). The median survival time (MST) was 3.8 months for grade 0, 9.4 months for grade 2, and 10.1 for grade 3. Landmark analysis of the second-line population revealed a hazard ratio of 0.52 (0.30-0.82) for grade 1 and 0.49 for grade 2 (0.28-0.72) (p < 0.05). MST was 1.3 months for grade 0, 4.7 months for grade 1, and 4.6 months for grade 2.

CONCLUSIONS

We found that neutropenia grade was an indicator of good prognosis in patients treated with first-line and second-line GEM for unresectable pancreatic cancer. A prospective study should be performed to examine whether dosage adjustment using neutropenia grade as an indicator would improve prognosis.

Evaluation of S100A4 mRNA in EUS-FNA specimens for the assessment of chemosensitivity to gemcitabine from patients with unresectable pancreatic cancer

BACKGROUND/AIMS

Gemcitabine (GEM) is the first-line chemotherapy in patients with unresectable pancreatic cancer. However, the clinical outcomes of this regimen are still unsatisfactory in prolonging survival. Resistant to GEM is one of the reasons for poor prognosis. Therefore, looking for molecular biomarkers to predict chemosensitivity to GEM is important for treatment in unresectable pancreatic cancer patients. The aim of this study was to analyze S100A4 mRNA in tissues of unresectable pancreatic cancer obtained by endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA), and to determine the relation between S100A4 mRNA level and chemosensitivity to GEM.

METHODS

The analysis was performed on samples from 36 patients with unresectable pancreatic cancer who were treated with gemcitabine alone. The patients were assigned to receive GEM at 1,000 mg/m(2)/wk for weeks 1 to 6, followed by 1 week rest, then for 4 weeks. mRNA was extracted for S100A4 mRNA assay from patients above by EUS-FNA before GEM-treatment. The 36 patients were divided into the following two groups. Patients with partial response and those with stable disease whose tumor markers decreased by 50% or more were classified as the effective group. The rest of patients were classified as the non effective group. The relationship between GEM efficacy and S100A4 mRNA expression was then examined by chi-squared test.

RESULTS

S100A4 mRNA showed a significant correlation with GEM efficacy. Patients in the effective group had low S100A4 mRNA expression, whereas patients in non-effective group had high S100A4 mRNA expressions (P = 0.0059).

CONCLUSION

S100A4 mRNA level analyzed in EUS-FNA samples is an important molecular biomarker for prediction of chemosensitivity to GEM in unresectable pancreatic cancer.

The clinical utility of image-guided iodine-125 seed in patients with unresectable pancreatic cancer

In the present study, we investigated the clinical effects of image-guided iodine-125 ((125)I) seed on unresectable pancreatic cancer. Twenty-five patients with unresectable pancreatic cancer were enrolled in this study, including 13 patients with seed implantation and 12 patients as control. The survival status, clinical benefits, objective curative effects, and relevant tumor markers were analyzed to assess the feasibility and safety of interstitial (125)I seed implantation. We found that the clinical benefit rate of the seed implantation group is 92.3 % (12/13), compared with 41.7 % (5/12) in the control, and the difference was statistically significant (p < 0.01). Compared with control, patients with seed implantation had significantly shorter operative time, less bleeding, higher albumin, shorter periods to bowel movement, and normal diet as well as lower risk of complications (p < 0.001). The differences of objective curative effects adverse effects, complications, and median survival between these two groups were not significant statistically (p > 0.05). In conclusion, (125)I seed implantation provides a safe and effective method to inhibit the tumor development, relieve pain, and improve quality of life for unresectable pancreatic cancer. These findings need to be validated by conducting further studies with larger cohorts.

Role of adjuvant surgery in initially unresectable pancreatic cancer after long-term chemotherapy or chemoradiation therapy: survival benefit?

BACKGROUND

The purpose of the present study was to analyze the survival benefit and safety of adjuvant surgery in patients with initially unresectable pancreatic cancer following chemo(radio)therapy.

METHODS

The 130 patients with unresectable pancreatic cancer treated during 2006 to 2013 were divided into a study group (15 patients) with planned adjuvant surgery, and a control group (115 patients with locally advanced disease) without adjuvant surgery.

RESULTS

The study group of 15 patients had shrunken tumor, decreased tumor marker, and maintained performance status after 9 months (range 5-18 months) of chemo(radio)therapy. Thirteen patients had curative resection and two patients were not resected. The remaining controls of 115 patients did not undergo surgical resection due to poor response to chemo(radio)therapy or performance status. The median survival time in the study group was better than in the control group (36 vs. 9 months, P < 0.001). The mortality and morbidity rates in the study group were 0% and 46% respectively, in spite of concomitant organ resections in 77%.

CONCLUSION

Patients who had adjuvant surgery had significant improvement of survival without increase in morbidity and mortality, relative to patients with locally advanced disease. Thus, adjuvant surgery may provide the promising results in this group who responded favorably to initial chemo(radio)therapy in unresectable pancreatic cancer.

Gastrojejunostomy in patients with unresectable pancreatic head cancer - the use of Roux loop significantly shortens the hospital length of stay

AIM: To evaluate the use of the Roux loop on the postoperative course in patients submitted for gastroenteroanastomosis (GE).

METHODS: Non-jaundiced patients (n = 41) operated on in the Department of General and Transplant Surgery in Lodz, between January 2010 and December 2011 were enrolled. The tumor was considered unresectable when liver metastases or major vascular involvement were confirmed. Patients were randomized to receive Roux (n = 21) or conventional GE (n = 20) on a prophylactic basis.

RESULTS: The mean time to nasogastric tube withdrawal in Roux GE group was shorter (1.4 ± 0.75 vs 2.8 ± 1.1, P < 0.001). Time to starting oral liquids, soft diet and regular diet were decreased (2.3 ± 0.86 vs 3.45 ± 1.19; P < 0.001; 3.3 ± 0.73 vs 4.4 ± 1.23, P < 0.001 and 4.5 ± 0.76 vs 5.6 ± 1.42, P = 0.002; respectively). The Roux GE group had a lower use of prokinetics (10 mg thrice daily for 2.2 ± 1.8 d vs 3.7 ± 2.6 d, P = 0.044; total 62 ± 49 mg vs 111 ± 79 mg, P = 0.025). The mean hospitalization time following Roux GE was shorter (7.7 d vs 9.6 d, P = 0.006). Delayed gastric emptying (DGE) was confirmed in 20% after conventional GE but in none of the patients following Roux GE.

CONCLUSION: Roux gastrojejunostomy during open abdomen exploration in patients with unresectable pancreatic cancer is easy to perform, decreases the incidence of DGE and lowers hospitalization time.

Intraoperative radiofrequency ablation combined with 125iodine seed implantation for unresectable pancreatic cancer

AIM: To evaluate the feasibility, efficacy and safety of intraoperative radiofrequency ablation (RFA) combined with ¹²⁵iodine seed implantation for unresectable pancreatic cancer.

METHODS: Thirty-two patients (21 males and 11 females) at the age of 68 years (range 48-90 years) with unresectable locally advanced pancreatic cancer admitted to our hospital from January 2006 to May 2008 were enrolled in this study. The tumor, 4-12 cm in diameter, located in pancreatic head of 23 patients and in pancreatic body and tail of 9 patients, was found to be unresectable during operation. Diagnosis of pancreatic cancer was made through intraoperative biopsy. Patients were treated with FRA combined with ¹²⁵iodine seed implantation. In brief, a RFA needle was placed, which was confirmed by intraoperative ultrasound to decrease the potential injury of surrounding vital structures, a ¹²⁵iodine seed was implanted near the blood vessels and around the tumor border followed by bypass palliative procedure (cholangio-jejunostomy and/or gastrojejunostomy) in 29 patients.

RESULTS: The serum CA 19-9 level was decreased from 512 ± 86 U/mL before operation to 176 ± 64 U/mL, 108 ± 42 U/mL and 114 ± 48 U/mL, respectively, 1, 3 and 6 mo after operation (P < 0.05). The pain score on day 7 after operation, 1 and 3 mo after combined therapy was decreased from 5.86 ± 1.92 before operation to 2.65 ± 1.04, 1.65 ± 0.88 and 2.03 ± 1.16, respectively, after operation (P < 0.05). The rate of complete response (CR), partial response (PR), stable disease (SD), progressive disease (PD) in 32 patients was 21.8% (7/32), 56.3% (18/32), 15.6% (5/32) and 6.3% (2/32), respectively, 6 mo after operation, with a median overall survival time of 17. 5 mo. The median survival time of patients at stage III was longer than that of those at stage IV (19 mo vs 10 mo, P = 0.0026). The median survival time of patients who received and did not receive chemotherapy after operation was 20 mo and 16 mo, respectively (P = 0.0176). Of the 32 patients, 3 (10.6%) experienced postoperative complications including transient biliary leaks in 2 patients and acute pancreatitis in 1 patient. All the patients recovered well after conservative support treatment.

CONCLUSION: Intraoperative RFA combined with ¹²⁵iodine seed implantation is a feasible and safe procedure for unresectable pancreatic cancer with acceptable minor complications, and can prolong the survival time of patients, especially those at stage III.

Endoscopic biliary drainage for patients with unresectable pancreatic cancer with obstructive jaundice who are to undergo gemcitabine chemotherapy

AIM: To assess optimum endoscopic biliary drainage (EBD) in cases with unresectable pancreatic cancer in the era of gemcitabine (GEM).

METHODS: Thirty patients with unresectable pancreatic cancer, who presented with jaundice and underwent chemotherapy using GEM after EBD were included in this study (GEM group). Fifteen cases with the same clinical manifestation and stage of pancreatic cancer treated with EBD alone were also included as controls. A covered metallic stent (CMS) or a plastic stent (PS) was used for EBD. The mean survival time (MST) in each group, risk factors of survival time, type of stent used and associated survival time, occlusion rate of stent, patency period of stent, and risk factors of stent occlusion were evaluated.

RESULTS: MST in the GEM group was longer than that in the control (9.9 mo vs 6.2 mo). In the GEM group, the survival time was not different between those who underwent metallic stenting and those who underwent plastic stenting. Stent occlusion occurred in 60% of the PS group and 7% of the CMS group. The median stent patency in the PS-GEM group and the CMS-GEM group was 5 mo and 7.5 mo, respectively. Use of a PS was the only risk factor of stent occlusion.

CONCLUSION: A CMS is recommended in cases presenting with jaundice due to unresectable pancreatic cancer, since the use of a CMS makes it possible to continue chemotherapy using GEM without repetition of stent replacement.