Preoperative chemoradiation for adenocarcinoma of the pancreas and duodenum

Long-term follow-up of twenty patients with adenocarcinoma of the pancreas: resection following combined modality therapy

Long-term follow-up of 5 or more years in 20 patients with initially unresectable cancer of the pancreas that responded to chemoradiation therapy is detailed in this article. All patients underwent resection. Seven or 18 surgical survivors are alive 50 or more months.

Intensified adjuvant combined modality therapy for resected periampullary adenocarcinoma: acceptable toxicity and suggestion of improved 1-year disease-free survival

PURPOSE

(1) To determine the toxicity of an intensified postoperative adjuvant regimen for periampullary adenocarcinoma (pancreatic and nonpancreatic) utilizing concurrent 5-fluorouracil (5-FU), leucovorin (LV), dipyridamole (DPM), and mitomycin-C (MMC) combined with split-course locoregional external beam radiotherapy (EBRT) to 50 Gy. This was followed by 4 cycles of the same chemotherapy as adjuvant therapy. (2) To determine preliminary estimates of the overall and disease-free survival associated with the use of this regimen. (3) To compare the toxicities and early survival results of patients treated with the current regimen to those of patients who completed our prior trial of concurrent chemoradiation infusion with 5-FU/LV chemotherapy and regional nodal and prophylactic hepatic irradiation.

METHODS

Postpancreaticoduodenectomy, patients received every 4 weeks bolus administration of 5-FU, (400 mg/m(2)), and LV, (20 mg/m(2), Days l-3), DPM (75 mg p.o., 4 times per day, Days 0-3, and every 8 weeks), MMC, (10 mg/m(2); maximum of 20 mg, Day l during EBRT). This was followed by 4 months of the same chemotherapy, beginning 1 month following the completion of EBRT. EBRT consisted of split-course 5000 cGy/20 fractions with a 2-week planned rest after the first 10 fractions (2500 cGy).

RESULTS

From 4/96 to 6/99, 45 patients were enrolled and treated. Their experience constitutes the basis of this analysis. There were 29 patients with pancreatic cancer and 16 with nonpancreatic periampullary cancer. Seventeen patients had tumors of 3 cm or more, and 39 patients had at least 1 histologically involved lymph node. Thirteen patients had a histologically positive margin of resection. The mean time to start of treatment was 63 days following surgery. During chemoradiation therapy there were no Grade 3 or worse nonhematologic toxicities and 47% Grade 3 or Grade 4 hematologic toxicities of short duration. Following chemoradiation, during chemotherapy treatment only, there was one Grade 3 hepatic and one Grade 3 pulmonary toxicity which was nondebilitating (2% each case) and 42% Grade 3 or 4 hematologic toxicity. There were 2 episodes of neutropenic fever requiring admission and no treatment-related mortalities. One patient developed a mild case of HUS, which responded to standard management. One patient developed persistent shortness of breath (nondebilitating), and another patient had occasional dyspnea on exertion, both occurring after all therapy. The majority of patients complained of increased fatigue (Grade 1-2), greatest during the combined therapy and improving post all treatment. As of 6/23/99, 20 of 45 patients have relapsed, 13 in the liver. Twelve patients have died. Median follow-up for surviving patients is 14.3 months. Disease-free survival at 12 months following surgery is 66% (as compared to 25% in our prior study), and the median disease-free survival is 17 months (as compared to 8. 3 months in our prior study). Median survival has not yet been reached, but will be greater than 17 months.

CONCLUSION

With a 14.3-month median follow-up, acute toxicity has been acceptable and manageable. Observed relapses were seen 9-13 months following surgical resection. Early survival analysis suggests a trend toward increased median disease-free survival (8.3 vs. 17 months), especially for patients with nonpancreatic periampullary adenocarcinoma.

New directions in systemic therapy of pancreatic cancer

BACKGROUND

The aggressiveness of pancreatic adenocarcinoma makes it a deadly disease, with its incidence rate and fatality rate almost equal. Surgery represents the only means to provide cure to patients with pancreatic cancer, though the 5-year survival is less than 10%.

METHODS

We review the data on surgical and systemic therapies and provide more details on a newer biologically based medical approach.

RESULTS

Neoadjuvant chemotherapy protocols are confined to one or two institutions, and adjuvant chemotherapy and chemoradiation therapy protocols are far from being standardized. Chemoradiation therapy for locally advanced pancreatic cancer offers limited benefits. Protocols that include gemcitabine and 5-fluorouracil, while comparing favorably to historical controls, offer median survivals at approximately 8 months.

CONCLUSIONS

More effective protocols with combinations of approaches agents are needed to improve the treatment of pancreatic cancer.

Neoadjuvant radio-chemotherapy in advanced primarilynon-resectable carcinomas of the pancreas

AIM

To investigate the feasibility of neoadjuvant radio-chemotherapy (RCT) in the treatment of primarily non-resectable pancreas carcinoma the parameters tumour regression, possibility of subsequent resection and tolerability were examined.

METHOD

Between 1995 and 1997, 27 patients with locally inoperable (assessed by CT criteria) pancreatic carcinoma received radio-chemotherapy for 5 weeks comprising irradiation (55.8 Gy) and chemotherapy with 5-fluorouracil (5-FU, 1000 mg/m(2)/day; 120 h continuous infusion) and mitomycin C (10 mg/m(2)i.v.-bolus, day 2 and day 30) during the first and fifth week of radiotherapy. Two target volumes were irradiated with fractionated doses of 1.8 Gy up to a total of 50.4 Gy. Radiation was applied once a day five times a week and target volume 1 was irradiated with the same fractionated dose, and an additional boost of 5.4 Gy to make an overall total of 55.8 Gy.

RESULTS

Sixteen patients underwent explorative laparotomy, 10 of these were resected (eight Whipple's procedures, two distal pancreatic resections), while six could not be resected due to peritoneal carcinosis (n=3), local irresectability (n=2) and liver cirrhosis (n=1). A further nine patients were found to have unresectable tumours on CT and did not undergo surgery after restaging (five of these patients were staged as <<locally irresectable>>, three patients had distant metastases and one patient refused surgery). In two patients RCT was abandoned because of progression of disease.

CONCLUSIONS

The study protocol described is feasible without significant acute toxicity and when used the resectability rate was improved; the survival rate, however, was not improved. Additional intra-arterial or intraportal application of such drugs as mitomycin C or cisplatin may be necessary.

Radiation therapy in pancreatic cancer: current practice and future trends

Treatment options for pancreatic cancer remain limited due to the large proportion of patients presenting with advanced disease at the time of diagnosis. Surgery offers the best chance for cure. Localized chemoradiation modestly improves median survival in both localized and locally advanced disease. Interstitial brachytherapy and intraoperative radiotherapy improve local control without providing significant impact on overall survival. Technological advances now allow us to deliver three dimensional conformal external beam irradiation with improved efficacy and decreased morbidity. Novel treatment approaches, such as intraoperative photoelectron radiation (Photon Radiosurgery System; PeC Photoelectron Corporation) and the development of more effective radiosensitizers, are presently under investigation.

[Concomitant chemoradiotherapy and preoperative radiotherapy in exocrine pancreatic adenocarcinoma]

The prognosis of pancreatic adenocarcinoma remains poor, with a 5-year survival rate lower than 5%. Resection, the gold standard treatment, can be performed in less than 10% of patients. Following surgery, the median survival is 12 months. Concomitant chemoradiation, as an adjuvant treatment could be superior to surgery alone, in terms of survival; controlled trials are currently performed. Neoadjuvant chemoradiation is a new approach, potentially able to increase survival and resection rate. Finally, current data regarding intraoperative irradiation are exposed.

[Adenocarcinoma of the exocrine pancreas: management and therapeutic hopes]

INTRODUCTION

Pancreatic carcinoma is a major public health concern, as it kills more than 6,000 people each year in France.

CURRENT KNOWLEDGE AND KEY POINTS

The main risk factor demonstrated by concordant case-control studies is cigarette smoking. Pancreatic carcinoma is generally diagnosed at an advanced stage. Results of radical surgery are still poor. In most of the reported series, less than 25% of the patients survive at five years.

FUTURE PROSPECTS AND PROJECTS

Postoperative radiochemotherapy slightly increases the hope of cure. In locally advanced tumors, radiochemotherapy, sometimes preoperative, allows some patients to survive more than two years. Though results of palliative chemotherapy remain very poor, some clinical benefit has been observed in randomized trials comparing this treatment with the currently best supportive treatment.

Chemoradiotherapy in the management of localized tumors of the pancreas

In western countries, carcinoma of the pancreas remains the most lethal of the common malignancies. Even the favorable "organ-confined" tumors present a considerable challenge. The lack of anatomic barriers to local infiltration and the biological propensity for early lymphatic, perineural, and vascular invasion are nearly insurmountable obstacles to complete surgical eradication of this malignancy. Various combinations of chemotherapy and radiotherapy (RT) have been used with marginal but measurable success. Earlier trials conducted by the Gastrointestinal Tumor Study Group established roles for 5-fluorouracil chemotherapy and RT in the treatment of patients with resectable or locally advanced pancreatic cancer. More recently, computed tomography-guided conformal RT and a variety of intraoperative RT techniques have enabled more reliable sterilization of the local surgical field and escalation of doses to potentially curative levels (7000 cGy) for unresectable lesions. Chemotherapy dose intensification through the use of portable programmable pumps for protracted venous infusions and the development of active systemic agents in addition to 5-fluorouracil suggest that an effective combination chemotherapeutic regimen might soon be developed. This report reviews the current standards of practice and integrates recent developments to construct a modern algorithm for the use of chemoradiotherapy in the management of localized (nonmetastatic) pancreatic cancer. The likely directions of future investigations are also discussed.

[Concomitant chemoradiotherapy in the therapeutic strategy of adenocarcinoma of the exocrine pancreas and stomach]

The prognosis of pancreatic adenocarcinoma remains poor, with a 5-year survival rate lower than 5%. Resection, the gold standard treatment, can be performed in less than 10% of patients. Following surgery, the median survival is 12 months for the most favorable cancer patients. Concomitant chemoradiation, as an adjuvant treatment is superior to surgery alone, in terms of survival; controlled trials are currently performed. Neoadjuvant chemoradiation is a new approach, potentially able to increase survival and resection rate. This work justifies the role of these schemes, in terms of modalities and potential advantages. A second part is dedicated to gastric carcinoma, with a review of the current results of chemoradiation, whose efficiency, even though a trend can be observed, remains to be proven. Prospective adjuvant combined treatments are ongoing, in France and in the States.

[Does neoadjuvant radiochemotherapy augment the resectability of pancreatic cancers?]

PURPOSE OF THE STUDY

Pre-operative radiochemotherapy is the most recent therapeutic option in the pre-operative downstaging of pancreatic cancer and in decreasing the rate of positive resection margins. The purpose of the study was to evaluate tolerance and efficacy of pre-operative radiochemotherapy in unresectable pancreatic cancers.

MATERIAL AND METHODS

This study included seven cases of pancreatic cancer considered unresectable. The patients received preoperatively 50 grays within a 5-week period associated with 5 FU and Platin during the 1st and 5th weeks.

RESULTS

After radiochemotherapy, tomodensitometric evaluation showed a minor response in two cases. A pancreatico-duodenectomy could be performed in these two patients without any increase of pre- or post-operative morbidity or mortality.

CONCLUSIONS

The results of the study suggest that preoperative radiochemotherapy may increase pancreatic cancer resectability. This hypothesis should be confirmed by a prospective randomised trial.

Review article: current treatment and optimal patient management in pancreatic cancer

This review analyses the current state of knowledge and understanding concerning the optimum treatment and therapeutic management of patients who suffer from pancreatic cancer. It outlines recent advances in scientific understanding and assesses their potential future value to clinicians in confronting this disease. Despite a significant expansion in scientific knowledge relating to factors underlying the early development of pancreatic carcinoma, the clinician continues to be restricted to a severely limited therapeutic armoury for this disease. Local therapies (surgery and radiation) are inevitably of limited value in the face of a disease that is normally encountered at a stage where metastasis is already highly developed. Despite such limitations, however, surgery performed in specialist units may be of value for 10-20% of patients, with a 5-year survival rate in such units of between 10 and 24%. This may be improved even further by appropriate use of adjuvant treatment. The advanced stage of the disease when normally encountered emphasizes the potential value of systemic treatment in this therapeutic area. Unfortunately systemic treatment (chemotherapy) has been found to be ineffective to date in significantly extending survival, with a low rate and duration of remission being identified in most trials. The challenge for both the health service and the pharmaceutical industry is to harness recent and future developments in scientific knowledge to the practical benefit of clinicians. Where cure is possible it should be vigorously pursued; where it is not, in this field above all others, clinicians have a duty of care. To achieve this it is necessary to abandon the therapeutic nihilism that has characterized the attitudes of clinicians towards this disease in the past. It is time that such nihilism was replaced by a recognition of the challenges and the opportunities available to clinicians in enhancing the quantity and quality of life available to patients. The dictum of 'curing whenever possible but caring always' should be the future therapeutic philosophy used to guide clinicians in this important and rapidly changing therapeutic area.

The Royal Marsden experience of a small bowel adenocarcinoma treated with protracted venous infusion 5-fluorouracil

The purpose of this study was to review the efficacy of a protracted venous infusion of 5-fluorouracil (PVI 5-FU)-based chemotherapy in advanced small bowel adenocarcinoma. Data on all patients with small bowel malignancy who were seen at a single institution over a 5-year period were retrieved from the gastrointestinal unit and hospital databases, and these cases were reviewed. Eight patients with advanced small bowel adenocarcinoma received PVI 5FU-based chemotherapy. The overall response rate in assessable patients was 37.5% (3/8). The median overall survival was 13 months (range 1-28), and progression-free survival was 7.8 months (range 0-15). Overall, the treatment was well tolerated and symptomatic benefit was seen. In conclusion, PVI 5-FU has activity in this disease. This should be assessed either as a single agent or as part of a combination regimen such as epirubicin/cisplatin/PVI FU (ECF) in a multicentre randomized study.

[Role of adjuvant chemoradiotherapy in the therapeutic strategy of exocrine adenocarcinoma of the pancreas]

The prognosis of pancreatic adenocarcinoma remains poor, with a 5-year survival rate lower than 5%. Resection, the gold standard treatment, can be performed in less than 10% of patients. Following surgery, the median survival is 12 months for the most favorable patients. Concomitant chemoradiation, as an adjuvant treatment is superior to surgery alone, in terms of survival, controlled trials are currently performed. Neoadjuvant chemoradiation is a new approach, potentially able to increase survival and resection rate. This work justifies the role of these schemes, in terms of modalities and potential advantages.

Pancreaticoduodenectomy for pancreatic adenocarcinoma: postoperative adjuvant chemoradiation improves survival. A prospective, single-institution experience

OBJECTIVE

This study was designed to evaluate prospectively survival after pancreaticoduodenectomy for pancreatic adenocarcinoma, comparing two different postoperative adjuvant chemoradiation protocol to those of no adjuvant therapy.

SUMMARY BACKGROUND DATA

Based on limited data from the Gastrointestinal Tumor Study Group, adjuvant chemoradiation therapy has been recommended after pancreaticoduodenectomy for adenocarcinoma of the head, neck, or uncinate process of the pancrease. However, many patients continue to receive no such therapy.

METHODS

From October 1991 through September 1995, all patients with resected, pathologically confirmed adenocarcinoma of the head, neck, or uncinate process of the pancreas were reviewed by a multidisciplinary group (surgery, radiation oncology, medical oncology, and pathology) and were offered three options for postoperative treatment after pancreaticoduodenectomy: 1) standard therapy: external beam radiation therapy to the pancreatic bed (4000-4500 cGy) given with two 3-day fluorouracil (5-FU) courses and followed by weekly bolus 5-FU (500 mg/m2 per day) for 4 months; 2) intensive therapy: external beam radiation therapy to the pancreatic bed (5040-5760 cGy) with prophylactic hepatic irradiation (2340-2700 cGy) given with and followed by infusional 5-FU (200 mg/m2 per day) plus leucovorin (5 mg/m2 per day) for 5 of 7 days for 4 months; or 3) no therapy: no postoperative radiation therapy or chemotherapy.

RESULTS

Pancreaticoduodenectomy was performed in 174 patients, with 1 in-hospital death (0.6%). Ninety-nine patients elected standard therapy, 21 elected intensive therapy, and 53 patients declined therapy. The three groups were comparable with respect to race, gender, intraoperative blood loss, tumor differentiation, lymph node status, tumor diameter, and resection margin status. Univariate analyses indicated that tumor diameter < 3 cm, intraoperative blood loss < 700 mL, absence of intraoperative blood transfusions, and use of adjuvant chemoradiation therapy were associated with significantly longer survival (p < 0.05). By Cox proportional hazards survival analysis, the most powerful predictors of outcome were tumor diameter, intraoperative blood loss, status of resection margins, and use of postoperative adjuvant therapy. The use of postoperative adjuvant chemoradiation therapy was a predictor of improved survival (median survival, 19.5 months compared to 13.5 months without therapy; p = 0.003). The intensive therapy group had no survival advantage when compared to that of the standard therapy group (median survival, 17.5 months vs. 21 months, p = not significant).

CONCLUSIONS

Adjuvant chemoradiation therapy significantly improves survival after pancreaticoduodenectomy for adenocarcinoma of the head, neck, or uncinate process of the pancreas. Based on these survival data, standard adjuvant chemoradiation therapy appears to be indicated for patients treated by pancreaticoduodenectomy for adenocarcinoma of the head, neck, or uncinate process of the pancreas. Intensive therapy conferred no survival advantage over standard therapy in this analysis.

Brachytherapy and pancreatic cancer

Advances in diagnostic and therapeutic technology have not appreciably changed the outlook of patients with pancreatic cancer. While those patients presenting with localized resectable disease have the best prognosis, local control and intra-abdominal metastases remain significant obstacles to survival. Localized chemoradiation has modestly improved median survival in localized and locally advanced disease. Patients presenting with locally advanced disease at diagnosis benefit from surgical palliation which includes biliary and gastric bypass. Intraoperative interstitial brachytherapy has been effective when utilized at laparotomy to improve local control in locally advanced disease. Advances in laparoscopic techniques have provided the ability to more accurately stage patients prior to laparotomy and perform palliative procedures without the need for laparotomy. The utilization of high-dose-rate brachytherapy has proven effective in palliating obstructive symptoms with minimal morbidity on an outpatient basis. Recent efforts have focused on preoperative chemoradiation to improve resectability in selected patients and prophylactic hepatic irradiation to reduce metastases for patients with locally advanced disease.

Results of adjuvant therapy in resected pancreatic cancer

After an apparently curative resection, most patients develop local recurrence within the resection bed. In addition, almost all develop liver metastases. This implies that the surgical resection, even if extended, seldom is enough, and that an adjuvant treatment must be effective not only against systemic spread, but also against local recurrence. However, the time schedule may be different for different types of recurrence, resulting in different time frames for the adjuvant treatment. Although extended radical operations may increase the proportion of patients who can undergo resections, the incidence of local recurrences seems unchanged. There are, however, no randomized studies yet comparing the "Standard Whipple" with more extended resection. Intraoperative radiation (IORT) has failed to demonstrate a difference in long-term survival, but there have been reports of a decreased frequency of local progression at the site of the primary tumor. Therefore, it is encouraging that IORT seems to diminish the local recurrences after radical resections. However, randomized studies are also missing for this procedure. These are today only three published studies of adjuvant chemotherapy after radical pancreaticoduodenectomy, but a few more will be finished shortly. Still, the results have not convincingly shown that modern chemotherapy with or without radiotherapy prolongs the life of the patients, and there is little evidence for improving the quality of life. However, since the results are far from satisfactory after resection, more efforts should be made to find better treatment modalities, including adjuvant protocols.

In vitro chemosensitivity of human pancreatic cancer cell lines

CONCLUSION

These results show that eight pancreatic cancer cell lines are broadly sensitive to CDDP, and that chemotherapy for pancreatic cancer may improve the prognosis by more effective drug delivery to cancer cells.

BACKGROUND

Chemotherapy for pancreatic cancer does not satisfactorily improve prognosis. The efficacy of chemotherapy depends on choosing sensitive anticancer drugs.

METHODS

The in vitro chemosensitivity of eight human pancreatic cancer cell lines was investigated. Growth inhibition was measured by 3H-thymidine incorporation assays for doxorubicin hydrochloride (ADM), mitomycin C (MMC), cisplatin (CDDP), and etoposide (VP-16), and by Alamar Blue assay for (AB assay) 5-fluorouracil (5-FU). The cells were exposed to ADM, MMC, CDDP, and VP-16 for 2 h, and 5-FU for 72 h. From the dose-response curves, the 50% growth inhibition (IC50) level for each drug was estimated.

RESULTS

The IC50 after 2 h of exposure of each of the eight kinds of cell lines to each anticancer drug ranged from 0.12-8.2 micrograms/mL for ADM, 0.066-25 micrograms/mL for MMC, 0.57-7 micrograms/mL for CDDP, 0.68-300 micrograms/mL for VP-16. IC50 after 72 h of exposure to 5-FU ranged from 1.8-23 micrograms/mL.

Systemic and adjuvant therapy for patients with pancreatic carcinoma

BACKGROUND

Pancreatic cancer is a highly lethal disease with < or = 5% of patients surviving 5 years. There is no curative therapy for patients who cannot be surgically resected. Chemotherapy and radiation therapy can provide palliation but have not had a significant impact on 5-year survival.

METHODS

Newer approaches for improving the survival of patients with pancreatic cancer integrating chemotherapy, radiation therapy, and surgery are being evaluated. New chemotherapeutic agents (e.g., gemcitabine, camptothecins, taxanes, thymydilate synthase inhibitors, and fluorouracil-related compounds) are being studied alone and in combination with each other or different agents (e.g., trimetrexate or platinum-related compounds).

RESULTS

Increased knowledge about the biology of pancreatic cancer (including high frequency of ras and p53 mutations in neoplastic cells or the expression of a number of growth factor receptors on the cell surface) has lead to preclinical evaluation of novel approaches attempting to specifically target these. These novel approaches include gene therapy, vaccines, and antisense oligonucleotides targeted to genes important for proliferation or survival of pancreatic cancer cells.

CONCLUSIONS

Continued development of new approaches is needed to improve the treatment and survival of patients with pancreatic cancer.

Constipation and diarrhea: the neglected symptoms

OBJECTIVE

To review the symptom experience of constipation and diarrhea related to cancer and its treatment.

DATA SOURCES

Published articles and book chapters relating to constipation and diarrhea in patients with cancer.

CONCLUSIONS

Constipation and diarrhea often represent a major concern and source of discomfort for the cancer patients. Research is needed to establish prevention and treatment protocols for patients at risk for constipation or diarrhea.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses are in an excellent position to recognize individuals who are at high risk for constipation and diarrhea. Preventive strategies and treatment protocols are of utmost importance.

Adjuvant therapy with chemotherapy and radiation therapy in the management of carcinoma of the pancreatic head

Surgical resection remains the backbone of the curative management of carcinoma of the pancreatic head. The primary cause of recurrence appears to be residual locoregional subclinical disease. Data supporting the use and continued study of adjuvant chemotherapy and radiation therapy are summarized.

p53 protein accumulation in tumors of the ampulla of Vater

BACKGROUND

Accurate preoperative diagnosis of tumors of the ampulla of Vater is difficult because ampullary biopsies have a high false-negative rate. Recently, it has been suggested that p53 mutations in tumors of the ampulla of Vater are associated with the transformation of adenomas and low grade carcinomas to high grade carcinomas. The purpose of this study was to determine the extent of p53 protein accumulation in tumors of the ampulla of Vater, and to determine whether p53 accumulation can be detected in false-negative biopsies.

METHODS

Using a monoclonal anti-p53 antibody, sections of 4 normal ampullas, 5 adenomas, 17 carcinomas, and 9 initial biopsies of 9 of the tumors of the ampulla of Vater that had no morphologic evidence of carcinoma were immunostained.

RESULTS

None of the 4 normal ampullas (0%), 2 of 5 adenomas (40%), and 16 of 17 carcinomas (94%) were positive for p53. This p53 positivity was present through all stages of ampullary carcinoma. Of the nine initial biopsies negative for carcinoma, seven were positive for p53 and, of these, six (86%) were found to be carcinomas upon resection.

CONCLUSIONS

1) The molecular events leading to p53 accumulation in tumors of the ampulla of Vater occur early in the neoplastic process. 2) Tumors of the ampulla of Vater with biopsies negative for malignancy but positive for p53 are very likely to be carcinomas.