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Zhou Y, Liao S, You J, Wu H. Conversion surgery for initially unresectable pancreatic ductal adenocarcinoma following induction therapy: a systematic review of the published literature. Updates Surg 2021; 74:43-53. [PMID: 34021484 DOI: 10.1007/s13304-021-01089-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022]
Abstract
Patients with unresectable pancreatic ductal adenocarcinoma (UR-PDAC) are traditionally treated with palliative chemotherapy. The aim of this study was to evaluate the safety and efficacy of conversion surgery for initially UR-PDAC following induction therapy. The PubMed and Embase databases were systematically searched for eligible studies published between January 2000 and October 2020. Thirty-two series involving 1270 patients with 1056 locally advanced (LA) disease and 214 distant metastases were reviewed. The median mortality and morbidity was 0% (range 0-10%) and 47.1% (range 8.6-93.3%), respectively. Lymph-node negativity, negative resection margin and pathological complete response were observed in a median of 62.9% (38.5-90.9%), 84.4% (32.8-100%) and 6.7% (0-45.8%) of the specimens. The median survival was 32 (16.4-63.9) months with a 3-year survival rate of 47% (22-80%). Meta-analysis demonstrated that conversion surgery of initially UR-PDAC was associated with a significantly improved survival (hazard ratio [HR] = 0.55; 95% confidence intervals (CI) 0.45-0.66, P < 0.001). There was no significant difference in survival between the group with LA disease and that with distant metastases after conversion surgery (HR = 0.96; 95% CI 0.72-1.28, P = 0.790). Conversion surgery improved long-term survival of patients with initially UR-PDAC who had favorable response to induction therapy.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China.
| | - Shan Liao
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
| | - Jun You
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
| | - Huaxing Wu
- Department of Hepatobiliary and Pancreatovascular Surgery, First Hospital of Xiamen University, #55 Zhenhai Road, Xiamen, 361003, China
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Xu Y, Zhang Y, Wu Z, Wang D, Wu W, Kuang T, Lou W. Preoperative radiotherapy improves overall survival of pT4 pancreatic ductal adenocarcinoma patients after surgical resection. Jpn J Clin Oncol 2020; 50:679-687. [PMID: 32372083 DOI: 10.1093/jjco/hyaa035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/01/2020] [Accepted: 03/03/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim of delivering radiotherapy for pancreatic ductal adenocarcinoma patients was to sterilize vessel margin, increase R0 resection rate and delay local progression. Whether preoperative radiotherapy could prolong overall survival of surgical candidates remained unknown. METHODS Pancreatic ductal adenocarcinoma patients receiving radical resection from surveillance, epidemiology and end result database were enrolled. Propensity score matching was conducted to balance difference in baseline characteristics, and survival analyses were performed to compare overall survival between preoperative radiotherapy and upfront resection groups. Cox proportional hazard regression model and subgroup analyses were utilized to identify prognostic factors. RESULTS A total of 11 665 and 597 pancreatic ductal adenocarcinoma patients receiving upfront resection and preoperative radiotherapy followed by resection from 2004 to 2016 were identified, respectively, while baseline characteristics were distinct between groups. After propensity score matching, preoperative radiotherapy was not associated with better overall survival (upfront resection vs preoperative radiotherapy, 26 vs 27 months). Subgroup analyses showed that preoperative radiotherapy was a protective factor in pT4 (hazard ratio = 0.64, 95% confidence interval: 0.47-0.88) but a negative predictor in pT1 (hazard ratio = 1.79, 95% confidence interval: 1.08-2.97) patient populations. Survival analyses showed that preoperative radiotherapy improved overall survival of patients with pT4 stage (upfront resection vs preoperative radiotherapy, 19 vs 25 months) and involvement of celiac axis, superior mesenteric artery and aorta (upfront resection vs preoperative radiotherapy, 20 vs 27 months), while preoperative radiotherapy was associated with worse overall survival in patients with pT1 tumor (upfront resection vs preoperative radiotherapy, 39 vs 24 months). CONCLUSION Preoperative radiotherapy could improve survival of resected pancreatic ductal adenocarcinoma patients with pT4 stage or with celiac axis, superior mesenteric artery and aorta invasion.
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Affiliation(s)
- Yaolin Xu
- Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Yueming Zhang
- Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Zizhen Wu
- Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Dansong Wang
- Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Wenchuan Wu
- Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Tiantao Kuang
- Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Wenhui Lou
- Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
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Is a Pathological Complete Response Following Neoadjuvant Chemoradiation Associated With Prolonged Survival in Patients With Pancreatic Cancer? Ann Surg 2019; 268:1-8. [PMID: 29334562 DOI: 10.1097/sla.0000000000002672] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To describe the survival outcome of patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA-PDAC) who have a pathologic complete response (pCR) following neoadjuvant chemoradiation. BACKGROUND Patients with BR/LA-PDAC are often treated with neoadjuvant chemoradiation in an attempt to downstage the tumor. Uncommonly, a pCR may result. METHODS A retrospective review of a prospectively maintained database was performed at a single institution. pCR was defined as no viable tumor identified in the pancreas or lymph nodes by pathology. A near complete response (nCR) was defined as a primary tumor less than 1 cm, without nodal metastasis. Overall survival (OS) and disease-free survival (DFS) were reported. RESULTS One hundred eighty-six patients with BR/LA-PDAC underwent neoadjuvant chemoradiation and subsequent pancreatectomy. Nineteen patients (10%) had a pCR, 29 (16%) had an nCR, and the remaining 138 (74%) had a limited response. Median DFS was 26 months in patients with pCR, which was superior to nCR (12 months, P = 0.019) and limited response (12 months, P < 0.001). The median OS of nCR (27 months, P = 0.003) or limited response (26 months, P = 0.001) was less than that of pCR (more than 60 months). In multivariable analyses pCR was an independent prognostic factor for DFS (HR = 0.45; 0.22-0.93, P = 0.030) and OS (HR=0.41; 0.17-0.97, P = 0.044). Neoadjuvant FOLFIRINOX (HR=0.47; 0.26-0.87, P = 0.015) and negative lymph node status (HR=0.57; 0.36-0.90, P = 0.018) were also associated with improved survival. CONCLUSIONS Patients with BR/LA-PDAC who had a pCR after neoadjuvant chemoradiation had a significantly prolonged survival compared with those who had nCR or a limited response.
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Kurt E, Kurt M, Kanat O, Cetintas SK, Aygun S, Palazoglu T, Ozkan L, Evrensel T, Kaya E, Manavoglu O. Phase II Study of Induction Chemotherapy with Gemcitabine plus 5-Fluorouracil Followed by Gemcitabine-Based Concurrent Chemoradiotherapy for Unresectable Locally Advanced Pancreatic Cancer. TUMORI JOURNAL 2019; 92:481-6. [PMID: 17260487 DOI: 10.1177/030089160609200603] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and background To evaluate the efficacy and tolerability of a new treatment approach including induction chemotherapy (CT) and concurrent chemoradiotherapy (CRT) in unresectable, locally advanced pancreatic cancer (LAPC). Patients and methods Twenty-four patients with LAPC were enrolled in the study. They first received induction CT consisting of 5-fluorouracil (5FU) (500 mg/m2) and gemcitabine (1000 mg/m2), which were given weekly for 3 weeks of every 4. Patients showing a response or disease stabilization after 2 cycles of induction CT received CRT consisting of external beam radiotherapy (50.4-54 Gy in fractions of 1.8 Gy/day) and gemcitabine (350 mg/m2, weekly for 6 weeks). Patients without disease progression received 2 additional cycles of CT consisting of 5FU plus gemcitabine with the same doses and schedule as given in the induction CT. Results After the end of the study, 2 (8%) and 5 (21%) patients showed complete and partial responses, respectively. Five patients (21%) had disease stabilization. The grade 3 and 4 toxicities associated with CT were neutropenia (21%) and thrombocytopenia (4%). The grade 3 and 4 toxicities occurring in patients who received CRT were neutropenia (24%), thrombocytopenia (24%), diarrhea (18%), and nausea (12%). The median progression-free survival for all patients was 6 months (95% CI, 3.6-8.4), and the median overall survival was 11 months (95% CI, 8.16-13.84). Conclusions The CRT approach of this study is moderately active and has an acceptable toxicity profile. However, the incor-poration of combination CT into CRT at the present schedule could not produce any additional benefit over CRT alone. Newer agents with more systemic activity are clearly warranted.
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Affiliation(s)
- Ender Kurt
- Department of Medical Oncology, Uludag University, Faculty of Medicine, Bursa, Turkey.
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Advances of pathological complete response after neoadjuvant therapy for pancreatic cancer. JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Ettrich TJ, Berger AW, Perkhofer L, Daum S, König A, Dickhut A, Wittel U, Wille K, Geissler M, Algül H, Gallmeier E, Atzpodien J, Kornmann M, Muche R, Prasnikar N, Tannapfel A, Reinacher-Schick A, Uhl W, Seufferlein T. Neoadjuvant plus adjuvant or only adjuvant nab-paclitaxel plus gemcitabine for resectable pancreatic cancer - the NEONAX trial (AIO-PAK-0313), a prospective, randomized, controlled, phase II study of the AIO pancreatic cancer group. BMC Cancer 2018; 18:1298. [PMID: 30594153 PMCID: PMC6311014 DOI: 10.1186/s12885-018-5183-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 12/04/2018] [Indexed: 12/18/2022] Open
Abstract
Background Even clearly resectable pancreatic cancer still has an unfavorable prognosis. Neoadjuvant or perioperative therapies might improve the prognosis of these patients. Thus, evaluation of perioperative chemotherapy in resectable pancreatic cancer in a prospective, randomized trial is warranted. A substantial improvement in overall survival of patients with metastatic pancreatic cancer with FOLFIRINOX and nab-paclitaxel/gemcitabine vs standard gemcitabine has been demonstrated in phase III-trials. Indeed nab-paclitaxel/gemcitabine has a more favorable toxicity profile compared to the FOLFIRINOX protocol and appears applicable in a perioperative setting. Methods NEONAX is an interventional, prospective, randomized, controlled, open label, two sided phase II study with an unconnected analysis of the results in both experimental arms against a fixed survival probability (38% at 18 months with adjuvant gemcitabine), NCT02047513. NEONAX will enroll 166 patients with resectable pancreatic ductal adenocarcinoma (≤ cT3, N0 or N1, cM0) in two arms: Arm A (perioperative arm): 2 cycles nab-paclitaxel (125 mg/m2)/gemcitabine (1000 mg/m2, d1, 8 and 15 of an 28 day-cycle) followed by tumor surgery followed by 4 cycles nab-paclitaxel/gemcitabine, Arm B (adjuvant arm): tumor surgery followed by 6 cycles nab-paclitaxel/gemcitabine. The randomization (1:1) is eminent to avoid allocation bias between the groups. Randomization is stratified for tumor stage (ct1/2 vs. cT3) and lymph node status (cN0 vs. cN1). Primary objective is disease free survival (DFS) at 18 months after randomization. Key secondary objectives are 3-year overall survival (OS) rate and DFS rate, progression during neoadjuvant therapy, R0 and R1 resection rate, quality of life and correlation of DFS, OS and tumor regression with pharmacogenomic markers, tumor biomarkers and molecular analyses (ctDNA, transcriptome, miRNA-arrays). In addition, circulating tumor-DNA will be analyzed in patients with the best and the worst responses to the neoadjuvant treatment. The study was initiated in March 2015 in 26 centers for pancreatic surgery in Germany. Discussion The NEONAX trial is an innovative study on resectable pancreatic cancer and currently one of the largest trials in this field of research. It addresses the question of the role of intensified perioperative treatment with nab-paclitaxel plus gemcitabine in resectable pancreatic cancers to improve disease-free survival and offers a unique potential for translational research. Trial registration ClinicalTrials.gov: NCT02047513, 08/13/2014. Electronic supplementary material The online version of this article (10.1186/s12885-018-5183-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas J Ettrich
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Andreas W Berger
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Lukas Perkhofer
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Severin Daum
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité University Medicine Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Alexander König
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Andreas Dickhut
- Department of Oncology/Hematology, Fulda Hospital, Pacelliallee 4, 36043, Fulda, Germany
| | - Uwe Wittel
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Kai Wille
- Department of Hematology and medical oncology, Johannes-Wesling-Klinikum Minden, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Michael Geissler
- Department of Internal Medicine, Oncology/Hematology, Gastroenterology, Esslingen Hospital, Hirschlandstr. 97, 73730 Esslingen, Esslingen, Germany
| | - Hana Algül
- Department of Internal Medicine II, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Eike Gallmeier
- Department of Gastroenterology and Endocrinology, University of Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Jens Atzpodien
- Department of Medical Oncology and Hematology, Niels-Stensen-Kliniken, Alte Rothenfelder Str. 23, 49124, Georgsmarienhütte, Germany
| | - Marko Kornmann
- Department of General and Visceral Surgery, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Rainer Muche
- Institute of Epidemiology and Medical Biometry, University of Ulm, Schwabstrasse 13, 89081, Ulm, Germany
| | - Nicole Prasnikar
- Department of Oncologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22291, Hamburg, Germany
| | - Andrea Tannapfel
- Department of Pathology, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Anke Reinacher-Schick
- Department of Internal Medicine, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Waldemar Uhl
- Department of Surgery, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - Thomas Seufferlein
- Department of Internal Medicine I, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
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Outcomes after neoadjuvant treatment with gemcitabine and erlotinib followed by gemcitabine-erlotinib and radiotherapy for resectable pancreatic cancer (GEMCAD 10-03 trial). Cancer Chemother Pharmacol 2018; 82:935-943. [PMID: 30225601 DOI: 10.1007/s00280-018-3682-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/27/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) for pancreatic adenocarcinoma (PDAC) patients has shown promising results in non-randomized trials. This is a multi-institutional phase II trial of NAT in resectable PDAC patients. METHODS Patients with confirmed resectable PDAC after agreement by two expert radiologists were eligible. Patients received three cycles of GEM (1000 mg/m2/week) plus daily erlotinib (ERL) (100 mg/day). After re-staging, patients without progressive disease underwent 5 weeks of therapy with GEM (300 mg/m2/week), ERL 100 mg/day and concomitant radiotherapy (45 Gy). Efficacy was assessed using tumor regression grade (TRG) and resection margin status. Using a single-arm Simon's design, considering the therapy not useful if R0 < 40% and useful if the R0 > 70% (alpha 5%, beta 10%), 24 patients needed to be recruited. This trial was registered at ClinicalTrials.gov, number NCT01389440. RESULTS Twenty-five patients were enrolled. Adverse effects of NAT were mainly mild gastrointestinal disorders. Resectability rate was 76%, with a R0 rate of 63.1% among the resected patients. Median overall survival (OS) and disease-free survival (DFS) were 23.8 (95% CI 11.4-36.2) and 12.8 months (95% CI 8.6-17.1), respectively. R0 resection patients had better median OS, compared with patients with R1 resection or not resected (65.5 months vs. 15.5 months, p = 0.01). N0 rate among the resected patients was 63.1%, and showed a longer median OS (65.5 vs. 15.2 months, p = 0.009). CONCLUSION The results of this study confirm promising oncologic results with NAT for patients with resectable PDAC. Therefore, the present trial supports the development of phase II randomized trials comparing NAT vs. upfront surgery in resectable pancreatic cancer.
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Abstract
Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malignancy. This article updates an earlier experience of actual long-term survival of CaP in patients treated between 1991 to 2000, and reviews the literature. Survival is expressed as actual, not projected, survival.
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Abstract
OPINION STATEMENT Pancreatic adenocarcinoma 2030 (PCa) is predicted to be the second leading cause of cancer death in USA by 2030. To date, attempts at early detection have been unsuccessful. Therapies for resectable PCa include surgery followed by adjuvant chemotherapy with or without radiotherapy. Unfortunately, most patients with PCa present with advanced disease and thus only 20% of patients are potentially resectable upon presentation. Improved surgical techniques along with adjuvant combination chemotherapy have improved outcomes for patients with resectable disease. The optimal treatment approach for borderline resectable and locally advanced unresectable PCa has not yet been defined. Despite significant advances in the palliative treatment of PCa, long-term survival of early stage disease continues to be sobering. The key to improving outcomes for this largely fatal disease is to identify multidisciplinary therapeutic interventions including surgical, medical, and radiation techniques tailored to the patient and their disease characteristics. The neoadjuvant approach provides an in vivo platform to test novel treatment options to help us understand tumor biology and surrounding microenvironment, which may ultimately help us achieve the goal of improvement in long-term survival. While the neoadjuvant approach remains popular as a way to optimally select patients that might benefit most from surgery, randomized trials utilizing adjuvant and neoadjuvant novel therapies hold the key to truly personalizing the ideal treatment strategy for localized PCa.
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Sui K, Okabayashi T, Shima Y, Morita S, Iwata J, Sumiyoshi T, Saisaka Y, Hata Y, Noda Y, Matsumoto M, Nishioka A, Iiyama T, Shimada Y. Clinical effects of chemoradiotherapy in pursuit of optimal treatment of locally advanced unresectable pancreatic cancer. Br J Radiol 2017; 90:20170165. [PMID: 28590776 PMCID: PMC5594991 DOI: 10.1259/bjr.20170165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The treatment of locally advanced unresectable pancreatic cancer remains extremely challenging, particularly as the efficacy of concurrent chemoradiotherapy (CRT) remains unclear. METHODS We studied 93 patients (8.0%) with locally advanced unresectable pancreatic cancer without distant metastases from among a total group of 1168 patients who were diagnosed with pancreatic cancer from March 2005 to November 2015 at the Kochi Health Sciences Center, Kochi, Japan. We therefore evaluated the clinical efficacy of CRT in patients with locally advanced unresectable pancreatic cancer. RESULTS Of the 93 patients with locally advanced unresectable pancreatic cancer, 35 patients (37.6%) were subsequently classified as having resectable disease following CRT. The median overall survival of patients who received CRT alone for locally advanced unresectable pancreatic cancer was 8.0 months, and all died within 3 years. On the other hand, the overall 1-, 3- and 5-year survival rates in patients who were reclassified as having resectable tumour after CRT were 71.3%, 39.2% and 23.5%, respectively. Our pathological assessments after surgical resection suggested that CRT might be associated with a significant reduction in the risk of lymph node metastases in patients with locally advanced unresectable pancreatic cancer. CONCLUSION The results of this study suggested that CRT is clinically effective in improving survival, particularly in association with the resultant possibility of curative resection. Advances in knowledge: The best treatment strategy for patients with locally advanced unresectable pancreatic cancer is the subject of considerable debate, and CRT is only recommended if cancer has only grown around the pancreas without any distant metastases.
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Affiliation(s)
- Kenta Sui
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, Japan
| | - Takehiro Okabayashi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, Japan
| | - Yasuo Shima
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, Japan
| | - Sojiro Morita
- Department of Radiology, Kochi Health Sciences Center, Kochi, Japan
| | - Jun Iwata
- Department of Diagnostic Pathology, Kochi Health Sciences Center, Kochi, Japan
| | - Tatsuaki Sumiyoshi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, Japan
| | - Yuichi Saisaka
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, Japan
| | - Yasuhiro Hata
- Department of Radiology, Kochi Health Sciences Center, Kochi, Japan
| | - Yoshihiro Noda
- Department of Radiology, Kochi Health Sciences Center, Kochi, Japan
| | - Manabu Matsumoto
- Department of Diagnostic Pathology, Kochi Health Sciences Center, Kochi, Japan
| | - Akihito Nishioka
- Department of Radiology, Kochi Health Sciences Center, Kochi, Japan
| | - Tastuo Iiyama
- Department of Biostatistics, Kochi University School of Medicine, Kochi, Japan
| | - Yasuhiro Shimada
- Department of Clinical Oncology, Kochi Health Sciences Center, Kochi, Japan
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Tsutsumi H, Hara K, Mizuno N, Hijioka S, Imaoka H, Tajika M, Tanaka T, Ishihara M, Yoshimura K, Shimizu Y, Niwa Y, Sasaki Y, Yamao K. Clinical impact of preoperative endoscopic ultrasound-guided fine-needle aspiration for pancreatic ductal adenocarcinoma. Endosc Ultrasound 2016; 5:94-100. [PMID: 27080607 PMCID: PMC4850801 DOI: 10.4103/2303-9027.180472] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Aim: To reveal the impact of preoperative endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic ductal adenocarcinoma (PDAC). Materials and Methods: We retrospectively reviewed 242 patients who underwent surgery for PDAC at our institution between January 1996 and July 2012. Among them, there were three patients with R2 resection and 30 patients with a follow-up period of less than 1 year, who were excluded because they did not meet the conditions for evaluating recurrence. Consequently, 209 patients were enrolled in the present study. The patients were divided into two groups: 126 patients who underwent preoperative EUS-FNA (FNA group) and 83 patients who did not (non-FNA group) undergo preoperative EUS-FNA. Results: There were no significant differences in baseline characteristics between FNA and non-FNA groups except mean age (66.6 ± 8.9 years vs. 63.5 ± 8.9 years, respectively, P = 0.02) and the administration rate of gemcitabine as adjuvant chemotherapy (42.9% vs. 18.1%, P < 0.01). Sampling adequacy of preoperative EUS-FNA was 99.2% (125/126) and sensitivity for diagnosis was 92.9% (117/126). The rate of complications related to EUS-FNA was 1.6% (2/126); two patients experienced reduction in hemoglobin (≥2.0 g/dL). These two patients did not have any apparent bleeding and could be managed conservatively. No severe complications were seen. We evaluated long-term outcomes of preoperative EUS-FNA, especially disease-free survival, needle-track seeding and recurrence. Kaplan-Meier analysis indicated no significant difference in disease-free survival between the two groups (P = 0.12). The site of recurrence was not significantly different between groups. Needle-track seeding was not observed in this study. Multivariate analysis of recurrence factors showed that preoperative EUS-FNA did not affect postoperative recurrence. Conclusion: Preoperative EUS-FNA for PDAC was shown to be a safe procedure with high diagnostic ability, and not a risk factor for postoperative recurrence.
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Affiliation(s)
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
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Haqq J, Howells LM, Garcea G, Dennison AR. Targeting pancreatic cancer using a combination of gemcitabine with the omega-3 polyunsaturated fatty acid emulsion, Lipidem™. Mol Nutr Food Res 2015; 60:1437-47. [PMID: 26603273 DOI: 10.1002/mnfr.201500755] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 11/03/2015] [Accepted: 11/12/2015] [Indexed: 01/05/2023]
Abstract
SCOPE Pancreatic cancer remains a disease of poor prognosis, with alternate strategies being sought to improve therapeutic efficacy. Omega-3 fatty acids have shown clinical benefit, and mechanisms of action are under investigation. METHODS AND RESULTS Proliferation assays, flow cytometry, invasion assays, ELISA and western blotting were used to investigate efficacy of omega-3 fatty acids alone and in combination with gemcitabine. The docosahexanoic acid (DHA)/eicosapentanoic acid (EPA) combination, Lipidem™, in combination with gemcitabine inhibited growth in pancreatic cancer and pancreatic stellate cell (PSC) lines, with PSCs exhibiting greatest sensitivity to this combination. Invasion of pancreatic cancer cells and PSCs in a 3D spheroid model, was inhibited by combination of gemcitabine with Lipidem™. PSCs were required for cancer cell invasion in an organotypic co-culture model, with invasive capacity reduced by Lipidem™ alone. Platelet-derived growth factor (PDGF) is a key cytokine in pro-proliferative and invasion signalling, and thus a critical regulator of interactions between pancreatic cancer cells and adjacent stroma. Platelet-derived growth factor (PDGF-BB) secretion was completely inhibited by the combination of Lipidem™ with gemcitabine in cancer cells and PSCs. CONCLUSION Lipidem™ in combination with gemcitabine, has anti-proliferative and anti-invasive efficacy in vitro, with pancreatic stellate cells exhibiting the greatest sensitivity to this combination.
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Affiliation(s)
- Jonathan Haqq
- Department of Cancer Studies, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, , University of Leicester, Leicester, LE2 7LX, United Kingdom.,Department of Hepatobiliary Surgery, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, United Kingdom
| | - Lynne M Howells
- Department of Cancer Studies, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, , University of Leicester, Leicester, LE2 7LX, United Kingdom
| | - Giuseppe Garcea
- Department of Hepatobiliary Surgery, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, United Kingdom
| | - Ashley R Dennison
- Department of Hepatobiliary Surgery, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, United Kingdom
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Rashid OM, Pimiento JM, Gamenthaler AW, Nguyen P, Ha TT, Hutchinson T, Springett G, Hoffe S, Shridhar R, Hodul PJ, Johnson BL, Illig K, Armstrong PA, Centeno BA, Fulp WJ, Chen DT, Malafa MP. Outcomes of a Clinical Pathway for Borderline Resectable Pancreatic Cancer. Ann Surg Oncol 2015; 23:1371-9. [DOI: 10.1245/s10434-015-5006-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Indexed: 12/23/2022]
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Desai NV, Sliesoraitis S, Hughes SJ, Trevino JG, Zlotecki RA, Ivey AM, George TJ. Multidisciplinary neoadjuvant management for potentially curable pancreatic cancer. Cancer Med 2015; 4:1224-39. [PMID: 25766842 PMCID: PMC4559034 DOI: 10.1002/cam4.444] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/12/2015] [Accepted: 02/14/2015] [Indexed: 12/24/2022] Open
Abstract
Pancreatic adenocarcinoma remains the fourth leading cause of cancer mortality in the U.S. Despite advances in surgical technique, radiotherapy technologies, and chemotherapeutics, the 5-year survival rate remains approximately 20% for the 15% of patients who are eligible for surgical resection. The majority of this group suffers metastatic recurrence. However, despite advances in therapies for patients with advanced pancreatic cancer, only surgery has consistently proven to improve long-term survival. Various combinations of chemotherapy, biologic-targeted therapy, and radiotherapy have been evaluated in different settings to improve outcomes. In this context, a neoadjuvant (preoperative) treatment strategy offers numerous potential benefits: (1) ensuring delivery of early, systemic therapy, (2) improving selection of patients for surgical therapy with truly localized disease, (3) potential downstaging of the neoplasm facilitating a negative margin resection in patients with locally advanced disease, and (4) providing a superior clinical trial mechanism capable of rapid assessment of the efficacy of novel therapeutics. This article reviews the recent trends in the management of pancreatic adenocarcinoma, with a particular emphasis on a multidisciplinary neoadjuvant approach to treatment.
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Affiliation(s)
- Neelam V Desai
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Sarunas Sliesoraitis
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Steven J Hughes
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Jose G Trevino
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Robert A Zlotecki
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Alison M Ivey
- University of Florida Health Cancer Center, Gainesville, Florida
| | - Thomas J George
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
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Pancreatic cancer: diagnosis and treatments. Tumour Biol 2015; 36:1375-84. [PMID: 25680410 DOI: 10.1007/s13277-015-3223-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/03/2015] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cancer is one of the deadliest cancers, with exceptionally high mortality. Despite the relatively low incidence rate (10th), it is the fourth leading cause of cancer-related deaths in most developed countries. To improve the early diagnosis of pancreatic cancer and strengthen the standardized comprehensive treatment are still the main focus of pancreatic cancer research. Here, we summarized the rapid developments in the diagnosis and treatments of pancreatic cancer. Regarding diagnosis, we reviewed advances in medical imaging technology, tumor markers, molecular biology (e.g., gene mutation), and proteomics. Moreover, great progress has also been made in the treatments of this disease, including surgical resection, chemotherapy, targeted radiotherapy, targeted minimally invasive treatment, and molecular targeted therapy. Therefore, we also recapitulated the development, advantages, and disadvantages of each of the treatment methods in this review.
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Verbeke C, Löhr M, Karlsson JS, Del Chiaro M. Pathology reporting of pancreatic cancer following neoadjuvant therapy: challenges and uncertainties. Cancer Treat Rev 2015; 41:17-26. [PMID: 25434282 DOI: 10.1016/j.ctrv.2014.11.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/07/2014] [Accepted: 11/08/2014] [Indexed: 12/22/2022]
Abstract
An increasing number of studies investigate the use of neoadjuvant treatment for ductal adenocarcinoma of the pancreas. While a strong rationale supports this approach, study results are difficult to interpret and compare due to marked variance in multiple aspects of study design and performance. Divergence in pathology examination and reporting as a cause for heterogeneity and incomparability of study results has not been brought into this discussion yet, despite the fact that several key outcome measures for neoadjuvant treatment are pathology-based. This article discusses areas of controversy and difficulty regarding the evaluation of the extent of residual tumour tissue, grading of tumour regression and assessment of the margins, and explains the important clinical implications of the present uncertainty and divergence in pathology practice.
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Affiliation(s)
- C Verbeke
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institute, Hälsovägen, 141 86 Stockholm, Sweden; Department of Pathology & Cytology, Karolinska University Hospital, Hälsovägen, 141 86 Stockholm, Sweden.
| | - M Löhr
- Gastrocentrum, Karolinska Institute, Hälsovägen, 141 86 Stockholm, Sweden.
| | - J Severin Karlsson
- Department of Pathology & Cytology, Karolinska University Hospital, Hälsovägen, 141 86 Stockholm, Sweden.
| | - M Del Chiaro
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Hälsovägen, 141 86 Stockholm, Sweden.
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Golcher H, Brunner TB, Witzigmann H, Marti L, Bechstein WO, Bruns C, Jungnickel H, Schreiber S, Grabenbauer GG, Meyer T, Merkel S, Fietkau R, Hohenberger W. Neoadjuvant chemoradiation therapy with gemcitabine/cisplatin and surgery versus immediate surgery in resectable pancreatic cancer: results of the first prospective randomized phase II trial. Strahlenther Onkol 2014; 191:7-16. [PMID: 25252602 PMCID: PMC4289008 DOI: 10.1007/s00066-014-0737-7] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 07/23/2014] [Indexed: 12/15/2022]
Abstract
Background In nonrandomized trials, neoadjuvant treatment was reported to prolong survival in patients with pancreatic cancer. As neoadjuvant chemoradiation is established for the treatment of rectal cancer we examined the value of neoadjuvant chemoradiotherapy in pancreatic cancer in a randomized phase II trial. Radiological staging defining resectability was basic information prior to randomization in contrast to adjuvant therapy trials resting on pathological staging. Patients and methods Patients with resectable adenocarcinoma of the pancreatic head were randomized to primary surgery (Arm A) or neoadjuvant chemoradiotherapy followed by surgery (Arm B), which was followed by adjuvant chemotherapy in both arms. A total of 254 patients were required to detect a 4.33-month improvement in median overall survival (mOS). Results The trial was stopped after 73 patients; 66 patients were eligible for analysis. Twenty nine of 33 allocated patients received chemoradiotherapy. Radiotherapy was completed in all patients. Chemotherapy was changed in 3 patients due to toxicity. Tumor resection was performed in 23 vs. 19 patients (A vs. B). The R0 resection rate was 48 % (A) and 52 % (B, P = 0.81) and (y)pN0 was 30 % (A) vs. 39 % (B, P = 0.44), respectively. Postoperative complications were comparable in both groups. mOS was 14.4 vs. 17.4 months (A vs. B; intention-to-treat analysis; P = 0.96). After tumor resection, mOS was 18.9 vs. 25.0 months (A vs. B; P = 0.79). Conclusion This worldwide first randomized trial for neoadjuvant chemoradiotherapy in pancreatic cancer showed that neoadjuvant chemoradiation is safe with respect to toxicity, perioperative morbidity, and mortality. Nevertheless, the trial was terminated early due to slow recruiting and the results were not significant. ISRCTN78805636; NCT00335543. Electronic supplementary material The online version of this article (doi: 10.1007/s00066-014-0737-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henriette Golcher
- Department of Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany,
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Thani NAA, Keshavarz S, Lwaleed BA, Cooper AJ, Rooprai HK. Cytotoxicity of gemcitabine enhanced by polyphenolics from Aronia melanocarpa in pancreatic cancer cell line AsPC-1. J Clin Pathol 2014; 67:949-54. [PMID: 25232128 DOI: 10.1136/jclinpath-2013-202075] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AIMS Extending work with brain tumours, the hypothesis that micronutrients may usefully augment anticancer regimens, chokeberry (Aronia melanocarpa) extract was tested to establish whether it has pro-apoptotic effects in AsPC-1, an established human pancreatic cell line, and whether it potentiates cytotoxicity in combination with gemcitabine. Pancreatic cancer was chosen as a target, as its prognosis remains dismal despite advances in therapy. METHODS An MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-Diphenyltetrazolium Bromide) assay was used to assess the growth of the single pancreatic cancer cell line AsPC-1, alone and in comparison or combination with gemcitabine. This was backed up by flow cytometric DRAQ7 cell viability analysis. TUNEL assays were also carried out to investigate pro-apoptotic properties as responsible for the effects of chokeberry extract. RESULTS Chokeberry extract alone and its IC75 value (1 µg/mL) in combination with gemcitabine were used to assess the growth of the AsPC-1 cell line. Gemcitabine in combination with chokeberry extract was more effective than gemcitabine alone. TUNEL assays showed apoptosis to be a mechanism occurring at 1 µg/mL concentration of chokeberry, with apoptotic bodies detected by both colourimetric and fluorometric methods. CONCLUSIONS The implication of this study, using single cancer cell line, is that chemotherapy (at least with gemcitabine) might be usefully augmented with the use of micronutrients such as chokeberry extract.
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Affiliation(s)
| | - Sholeh Keshavarz
- School of Science and Technology, Middlesex University, The Burroughs, London, UK
| | - Bashir A Lwaleed
- Faculty of Health Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Alan J Cooper
- School of Pharmacy and Biomedical Sciences, Portsmouth University, Portsmouth, Hampshire, UK
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Opendro SS, Satoi S, Yanagimoto H, Yamamoto T, Toyokawa H, Hirooka S, Yamaki S, Inoue K, Matsui Y, Kwon AH. Role of adjuvant surgery in initially unresectable pancreatic cancer after long-term chemotherapy or chemoradiation therapy: survival benefit? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:695-702. [PMID: 24841048 DOI: 10.1002/jhbp.119] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
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.
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Affiliation(s)
- Singh Sapam Opendro
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka, 573-1010, Japan.
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A single-arm, nonrandomized phase II trial of neoadjuvant gemcitabine and oxaliplatin in patients with resectable pancreas adenocarcinoma. Ann Surg 2014; 260:142-8. [PMID: 24901360 DOI: 10.1097/sla.0000000000000251] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The role for neoadjuvant systemic therapy in resectable pancreas adenocarcinoma remains undefined. OBJECTIVE We evaluated the efficacy of gemcitabine and oxaliplatin administered as preoperative therapy in patients with resectable pancreas adenocarcinoma. METHODS Eligible patients were screened using computed tomography-pancreas angiography, laparoscopy, endoscopic ultrasonography, and fine-needle aspiration cytology to identify 38 patients who received 4 cycles of neoadjuvant gemcitabine 1000 mg/m intravenously over 100 minutes and oxaliplatin 80 mg/m intravenously over 2 hours, every 2 weeks. Patients whose tumors remained resectable at restaging proceeded to operation and subsequently received 5 cycles of adjuvant gemcitabine (1000 mg/m intravenously over 30 minutes days 1, 8, and 15 every 4 weeks). The primary endpoint was 18-month overall survival and secondary endpoints included radiological, tumor marker and pathological response to neoadjuvant therapy, time to recurrence, patterns of failure, and feasibility of obtaining preoperative core biopsies. RESULTS Thirty-five of 38 patients (92%) completed neoadjuvant therapy. Twenty-seven patients underwent tumor resection (resectability rate 71%), of which 26 initiated adjuvant therapy for a total of 23 patients (60.5%) who completed all planned therapy. The 18-month survival was 63% (24 patients alive). The median overall survival for all 38 patients was 27.2 months (95% confidence interval: 17-NA) and the median disease-specific survival was 30.6 months (95% confidence interval: 19-NA). CONCLUSIONS This study met its endpoint and provided a signal suggesting that exploration of neoadjuvant systemic therapy is worthy of further investigation in resectable pancreas adenocarcinoma. Improved patient selection and more active systemic regimens are key. Clinical trials identification: NCT00536874.
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Tachezy M, Gebauer F, Petersen C, Arnold D, Trepel M, Wegscheider K, Schafhausen P, Bockhorn M, Izbicki JR, Yekebas E. Sequential neoadjuvant chemoradiotherapy (CRT) followed by curative surgery vs. primary surgery alone for resectable, non-metastasized pancreatic adenocarcinoma: NEOPA- a randomized multicenter phase III study (NCT01900327, DRKS00003893, ISRCTN82191749). BMC Cancer 2014; 14:411. [PMID: 24906700 PMCID: PMC4057592 DOI: 10.1186/1471-2407-14-411] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 05/29/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Median OS after surgery in curative intent for non-metastasized pancreas cancer ranges under study conditions from 17.9 months to 23.6 months. Tumor recurrence occurs locally, at distant sites (liver, peritoneum, lungs), or both. Observational and autopsy series report local recurrence rates of up to 87% even after potentially "curative" R0 resection. To achieve better local control, neoadjuvant CRT has been suggested for preoperative tumour downsizing, to elevate the likelihood of curative, margin-negative R0 resection and to increase the OS rate. However, controlled, randomized trials addressing the impact of neoadjuvant CRT survival do not exist. METHODS/DESIGN The underlying hypothesis of this randomized, two-armed, open-label, multicenter, phase III trial is that neoadjuvant CRT increases the three-year overall survival by 12% compared to patients undergoing upfront surgery for resectable pancreatic cancer. A rigorous, standardized technique of histopathologically handling Whipple specimens will be applied at all participating centers. Overall, 410 patients (n=205 in each study arm) will be enrolled in the trial, taking into regard an expected drop out rate of 7% and allocated either to receive neoadjuvant CRT prior to surgery or to undergo surgery alone. Circumferential resection margin status, i.e. R0 and R1 rates, respectively, surgical resectability rate, local and distant disease-free and global survival, and first site of tumor recurrence constitute further essential endpoints of the trial. DISCUSSION For the first time, the NEOPA study investigates the impact of neoadjuvant CRT on survival of resectable pancreas head cancer in a prospectively randomized manner. The results of the study have the potential to change substantially the treatment regimen of pancreas cancer. TRIAL REGISTRATION Clinical Trial gov: NCT01900327, DRKS00003893, ISRCTN82191749.
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Affiliation(s)
- Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Florian Gebauer
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | | | - Dirk Arnold
- Clinic for Medical Oncology, Tumor Biology Center- Freiburg im Breisgau, Breisgau, Germany
| | - Martin Trepel
- University Cancer Center Hamburg (UCCH) - Hubertus Wald Tumor Center, Hamburg, Germany
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Phillipe Schafhausen
- University Cancer Center Hamburg (UCCH) - Hubertus Wald Tumor Center, Hamburg, Germany
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Jakob Robert Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Emre Yekebas
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg Eppendorf, Martinistr. 52, Hamburg 20246, Germany
- Departement of General, Visceral and Thoracic Surgery, Darmstadt Clinic, Darmstadt, Germany
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Jensen EH, Armstrong L, Lee C, Tuttle TM, Vickers SM, Sielaff T, Greeno EW. Neoadjuvant interferon-based chemoradiation for borderline resectable and locally advanced pancreas cancer: a Phase II pilot study. HPB (Oxford) 2014; 16:131-9. [PMID: 23509924 PMCID: PMC3921008 DOI: 10.1111/hpb.12086] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 11/24/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Neoadjuvant chemoradiotherapy (CRT) is a viable treatment strategy for patients with pancreatic cancer. This study was conducted to evaluate the Virginia Mason Protocol (5-fluorouracil, cisplatin, interferon-α and radiation) given in the neoadjuvant setting for the treatment of locally advanced pancreatic cancer. METHODS A Phase II pilot study evaluating interferon-based neoadjuvant CRT in patients with locally advanced pancreatic cancer was performed. RESULTS A total of 23 patients were enrolled. The mean age of the patients was 58.6 years. Of the 23 patients, seven (30.4%) completed all treatments. In the remaining 16 (69.6%) patients, treatment was interrupted as a result of toxicity. The most commonly reported effects of toxicity were leucopoenia/cytopoenia (n = 19, 82.6%) and gastrointestinal effects (n = 19, 82.6%). Surgical resection was successful in seven (30.4%) patients. Margins were negative in six (85.7%) of these seven patients. Positive lymph nodes were identified in three (42.9%) of seven patients. Overall survival was 11.5 months. Surgery provided improved survival (22.6 months) compared with CRT alone (8.8 months). Disease-free survival in resected patients was 17.2 months. CONCLUSIONS Interferon-based neoadjuvant CRT may allow for resection of locally advanced pancreatic cancer, but with significant toxicity. In the absence of surgical resection, survival remains dismal.
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Affiliation(s)
- Eric H Jensen
- Department of Surgery, University of Minnesota Medical CenterMinneapolis, MN, USA,Eric H. Jensen, Division of Surgical Oncology, University of Minnesota Medical Center, 420 Delaware Street SE, MMC 195, Minneapolis, MN 55455, USA. Tel: + 1 612 625 2991. Fax: +1 612 625 4406. E-mail:
| | - Leonard Armstrong
- Department of Surgery, University of Minnesota Medical CenterMinneapolis, MN, USA
| | - Chung Lee
- Department of Radiation Oncology, University of Minnesota Medical CenterMinneapolis, MN, USA
| | - Todd M Tuttle
- Department of Surgery, University of Minnesota Medical CenterMinneapolis, MN, USA
| | - Selwyn M Vickers
- Department of Surgery, University of Minnesota Medical CenterMinneapolis, MN, USA
| | - Timothy Sielaff
- Department of Surgery, Abbott Northwestern HospitalMinneapolis, MN, USA
| | - Edward W Greeno
- Department of Medicine, University of Minnesota Medical CenterMinneapolis, MN, USA
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Effect of chemoradiotherapy and neoadjuvant chemoradiotherapy in resectable pancreatic cancer: a systematic review and meta-analysis. J Cancer Res Clin Oncol 2013; 140:549-59. [PMID: 24370686 DOI: 10.1007/s00432-013-1572-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 12/13/2013] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Controversy remains existed whether chemoradiotherapy (CRT), especially neoadjuvant chemoradiotherapy (neoadjuvant CRT) achieves a significant benefit in resectable pancreatic cancer (PC) treatment. In this meta-analysis, we aimed to clarify the benefits of CRT and neoadjuvant CRT in resectable PC. METHODS Eligible trials were identified from MEDLINE, EMBASE, Cochrane center, China National Knowledge Internet and Wanfang database since their inception to July 31, 2013. Only patients with resectable PC, who underwent tumor resection and received CRT and/or neoadjuvant CRT, were enrolled. The treatment outcomes were overall survival (OS) and progression-free survival (PFS). Hazard ratio (HR) with a 95% confidence interval (CI) was used to measure the pooled effect according to a fixed-effects model. The statistical heterogeneity between trials was detected by χ(2) and I (2) test. Sensitivity analyses were also carried out. RESULTS A total of 28 studies were identified as relevant, but only 17 studies with a total of 3,088 patients were included in the comparison between CRT versus non-CRT, and a total number of three studies with 189 patients included in the comparison between neoadjuvant CRT versus postoperative CRT. The comparison between CRT and non-CRT showed that the overall pooled HR for death was 0.96 (95% CI 0.89-1.03; P = 0.28). The HR for progress was 0.83 (95% CI 0.68-1.03, P = 0.09). Comparison between neoadjuvant CRT and adjuvant CRT revealed a pooled HR of 0.93 (95% CI 0.69-1.25; P = 0.62). CONCLUSIONS This meta-analysis showed that CRT showed no significant effect on OS and PFS when compared to non-CRT. Neoadjuvant CRT showed no significant effect over postoperative adjuvant CRT.
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Ashman JB, Moss AA, Rule WG, Callister MG, Reddy KS, Mulligan DC, Collins JM, De Petris G, Gunderson LL, Borad M. Preoperative chemoradiation and IOERT for unresectable or borderline resectable pancreas cancer. J Gastrointest Oncol 2013; 4:352-60. [PMID: 24294506 DOI: 10.3978/j.issn.2078-6891.2013.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 01/24/2013] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pre-operative chemoradiation (preop CRT) plus intraoperative electron irradiation (IOERT) has been used in the multidisciplinary treatment for patients with locally advanced unresectable or borderline resectable pancreas cancer. This review was performed to evaluate survival, relapse patterns and prognostic factors in patients treated with curative intent. METHODS Between January 2002 and December 2010, 48 patients with locally advanced pancreatic ductal adenocarcinoma received preop CRT prior to an attempt at resection and IOERT. 31/48 (65%) patients proceeded to curative-intent surgical resection. Resection status prior to preop CRT was locally unresectable (20 patients) and borderline resectable (11 patients). Preop CRT (45-50.4 Gy/25-28 Fx in 27/31) was delivered with concurrent 5FU or gemcitabine-based regimens. Subsequent gross total resection was achieved in 16 patients (R0, 11; R1, 5). IOERT was delivered in 28 patients (dose, 10-20 Gy). 16 patients also received adjuvant post-operative systemic chemotherapy. Outcomes evaluated include survival, local failure in the EBRT field (LF), central failure in the IOERT field (CF), and distant metastases. RESULTS Resection status was predictive for survival and for patterns of relapse. For patients with at least a gross total resection after preop CRT (R0/R1; n=16) vs. no resection (n=15), both median and overall survival were improved (median 23 vs. 10 months; 2-year, 40% vs. 17%; 3-year, 40% vs. 0%; P=0.002). Liver or peritoneal relapse was documented in 22/31 patients (71%); LF/CF in 5/26 (16%). CONCLUSIONS Long term survival and disease control are achievable in select patients with borderline resectable or locally unresectable pancreas cancer when gross total surgical resection is achieved after preop CRT. Continued evaluation of curative-intent combined modality therapy is warranted in this high risk population, but additional strategies are needed to improve resectability and disease control.
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Affiliation(s)
- Jonathan B Ashman
- Department of Radiation Oncology, Mayo Clinic Cancer Center - Arizona (MCCC-A), Scottsdale/Phoenix, AZ, USA
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Chen KT, Devarajan K, Milestone BN, Cooper HS, Denlinger C, Cohen SJ, Meyer JE, Hoffman JP. Neoadjuvant chemoradiation and duration of chemotherapy before surgical resection for pancreatic cancer: does time interval between radiotherapy and surgery matter? Ann Surg Oncol 2013; 21:662-9. [PMID: 24276638 DOI: 10.1245/s10434-013-3396-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiation and chemotherapy provided for borderline or locally advanced, potentially resectable pancreatic adenocarcinoma improves resectability rates. Response to therapy is also an important prognostic factor. There are no data in the literature regarding optimal time interval or duration of chemotherapy after chemoradiation before surgery, and pathologic response rates. Using our database, we evaluated these relationships and the effect on overall and progression-free survival. METHODS We retrospectively analyzed the records of 83 patients who underwent neoadjuvant chemoradiation for locally advanced, potentially resectable, and borderline resectable pancreatic cancers before definitive resection. We divided patients into three groups according to time interval between completion of chemoradiation and resection: group A (0-10 weeks), group B (11-20 weeks), and group C (>20 weeks). After chemoradiation, patients underwent ongoing chemotherapy before resection. Pathologic response was defined as major (>95% fibrosis), partial (50-94% fibrosis), or minor (<50% fibrosis). RESULTS There were 56 patients in group A, 17 patients in group B, and 10 patients in group C. Patients in groups B and C were significantly more likely to experience a major response than group A (p < 0.013). Patients in group C had significantly increased median progression-free and overall survival (p < 0.05). Multivariable classification and regression tree analysis demonstrated pathologic response to be the only significant factor in overall survival. CONCLUSIONS Patients who underwent a prolonged time interval after neoadjuvant chemoradiation with ongoing chemotherapy were more likely to have an improved pathologic response at time of surgical resection, which was associated with improved median overall survival.
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Affiliation(s)
- Kathryn T Chen
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA,
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Chatterjee D, Katz MH, Rashid A, Estrella JS, Wang H, Varadhachary GR, Wolff RA, Lee JE, Pisters PW, Abbruzzese JL, Fleming JB, Wang H. Pancreatic intraepithelial neoplasia and histological changes in non-neoplastic pancreas associated with neoadjuvant therapy in patients with pancreatic ductal adenocarcinoma. Histopathology 2013; 63:841-51. [PMID: 24111684 DOI: 10.1111/his.12234] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 07/20/2013] [Indexed: 12/12/2022]
Abstract
AIMS To study the histological changes in non-neoplastic pancreas and the effects on pancreatic intraepithelial neoplasia (PanIN) after neoadjuvant chemoradiation therapy (NCRT) for pancreatic ductal adenocarcinoma (PDAC). METHODS AND RESULTS We reviewed the archival H&E slides from 218 patients with PDAC who completed NCRT and pancreaticoduodenectomy. Sixty-five patients who underwent pancreaticoduodenectomy for PDAC without NCRT were used as controls. Various histological features were reviewed and correlated with NCRT and survival. The NCRT group had lower densities of PanIN2 (P = 0.004) and PanIN3 (P = 0.02) than the control group. The extent of fibrosis, the frequency of neuroma-like nerve proliferation and the frequency of islet cell aggregation were significantly higher in the NCRT group than in the control group (P < 0.05). The intensity of inflammation was less in the NCRT group than in the control group (P = 0.02). In the NCRT group, patents with moderate to severe fibrosis or grade 2 inflammation had poorer survival than those with mild fibrosis (P = 0.04) or those with grade 0 or grade 1 inflammation (P = 0.003), respectively. CONCLUSIONS Non-neoplastic pancreatic tissue from patients who received NCRT had a reduced density of high-grade PanIN lesions, more pancreatic fibrosis, and higher frequencies of neuroma-like nerve proliferation and islet cell aggregation, but less inflammation, compared to tissue from those who did not receive NCRT.
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Affiliation(s)
- Deyali Chatterjee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Neoadjuvant therapy for potentially resectable pancreatic cancer: an emerging paradigm? Curr Oncol Rep 2013; 15:162-9. [PMID: 23325567 DOI: 10.1007/s11912-012-0291-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although neoadjuvant chemoradiotherapy has been tested for more than two decades and can be safely delivered to patients with non-metastatic pancreatic cancer, no randomised trials have been reported until now. Here we provide an overview of the first randomised trial in patients with potentially resectable cancer and of the latest developments in neoadjuvant therapy for this group of patients. It is necessary to continue to perform clinical trials in this field to accurately identify the effect on survival and quality of life in patients with potentially resectable, borderline resectable and unresectable pancreatic cancer. Aspects of imaging for restaging and clinical prognostic factors are also discussed given they will be useful instruments for future trials.
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Denost Q, Laurent C, Adam JP, Capdepont M, Vendrely V, Collet D, Sa Cunha A. Pancreaticoduodenectomy following chemoradiotherapy for locally advanced adenocarcinoma of the pancreatic head. HPB (Oxford) 2013; 15:716-23. [PMID: 23458326 PMCID: PMC3948540 DOI: 10.1111/hpb.12039] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 11/24/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to assess oncological outcomes in patients treated with pancreaticoduodenectomy for advanced pancreatic head adenocarcinoma after preoperative chemoradiotherapy and to compare these with outcomes in patients treated with surgery alone. METHODS From 2004 to 2009, patients treated with pancreaticoduodenectomy for pancreatic head adenocarcinoma were included in a retrospective comparative study. Patients with locally advanced adenocarcinoma were treated with preoperative chemoradiotherapy (CRT group) and were compared with those treated with surgery alone (SURG group). RESULTS A total of 111 patients were included; these comprised 72 patients in the SURG group and 39 patients in the CRT group. The median follow-up was 21 months. Patients in the CRT group presented with a more advanced tumoral status. Microscopic resection rates were similar in both groups, but nodal status and vascular or lymphatic emboli were lower in the CRT group. At 3 years, the SURG and CRT groups exhibited similar overall (36% and 51%, respectively) and disease-free (35% and 37%, respectively) survival (P = 0.10). CONCLUSIONS In patients with advanced pancreatic head adenocarcinoma, a good response after preoperative chemoradiotherapy results in a survival rate similar to that in patients treated with surgery alone in whom the initial prognosis is better.
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Affiliation(s)
- Quentin Denost
- University Hospital Centre (CHU) Bordeaux, Haut-Lévêque Hospital, Digestive SurgeryBordeaux, France,CHU Bordeaux, Saint-André Hospital, Digestive SurgeryBordeaux, France,Correspondence Quentin Denost, Service de Chirurgie Digestive, Hôpital Haut-Lévêque, Avenue Magellan, 33600 Pessac, France. Tel: + 33 5 57 65 60 19. Fax: + 33 5 57 65 60 28. E-mail:
| | | | - Jean-Philippe Adam
- University Hospital Centre (CHU) Bordeaux, Haut-Lévêque Hospital, Digestive SurgeryBordeaux, France,CHU Bordeaux, Saint-André Hospital, Digestive SurgeryBordeaux, France
| | - Maylis Capdepont
- CHU Bordeaux, Saint-André Hospital, Digestive SurgeryBordeaux, France
| | - Veronique Vendrely
- University Hospital Centre (CHU) Bordeaux, Haut-Lévêque Hospital, Digestive SurgeryBordeaux, France,CHU Bordeaux, Saint-André Hospital, Digestive SurgeryBordeaux, France
| | - Denis Collet
- University Hospital Centre (CHU) Bordeaux, Haut-Lévêque Hospital, Digestive SurgeryBordeaux, France
| | - Antonio Sa Cunha
- University Hospital Centre (CHU) Bordeaux, Haut-Lévêque Hospital, Digestive SurgeryBordeaux, France
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Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines. Pancreas 2013; 42:1004-10. [PMID: 23532000 DOI: 10.1097/mpa.0b013e31827b2d7c] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the relevance of defining borderline resectable (BR) pancreatic cancer as a distinct entity in the treatment scheme of pancreatic cancer as proposed by the National Comprehensive Cancer Network. METHODS Among 375 patients with pancreatic cancer, 137 patients were deemed to have resectable disease (R) by preoperative imaging studies, whereas 96 were found to have an unresectable disease during surgery. The remaining 142 patients fulfilled the definition of BR and were further classified into 3 subgroups based on the National Comprehensive Cancer Network guidelines: portal vein invasion (PV[+]), common hepatic artery invasion (CHA[+]), and superior mesenteric artery invasion (SMA[+]). PV(+) was subdivided into types B, C, and D according to the degree of portal vein invasion. RESULTS Patients in the R group had significantly better survival than those in the PV(+) group (P = 0.0038), who in turn survived significantly longer than those classified as SMA(+) (P = 0.041). Type B patients survived significantly longer than did types C and D patients (P = 0.013 and P = 0.030, respectively). In PV(+) patients, compliance with postoperative chemotherapy at 3 and 6 months was 56.9% and 44.6%, respectively, substantially inferior to patients with resectable disease (72.6% and 54.7%, respectively). CONCLUSIONS The optimal treatment strategy may differ among various subgroups within the BR category.
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Tajima H, Kitagawa H, Tsukada T, Okamoto K, Nakanuma SI, Sakai S, Makino I, Furukawa H, Hayashi H, Oyama K, Inokuchi M, Nakagawara H, Miyashita T, Itoh H, Fujita H, Takamura H, Ninomiya I, Fushida S, Fujimura T, Ohta T, Koda W, Minami T, Ryu Y, Sanada J, Gabata T, Matsui O, Sai Y. Hepatic arterial infusion chemotherapy with gemcitabine and 5-fluorouracil or oral S-1 improves the prognosis of patients with postoperative liver metastases from pancreatic cancer. Mol Clin Oncol 2013; 1:869-874. [PMID: 24649263 PMCID: PMC3916203 DOI: 10.3892/mco.2013.152] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 04/23/2013] [Indexed: 01/13/2023] Open
Abstract
Hepatic metastasis is a common cause of treatment failure following resection of pancreatic cancer. In this study, we report our results of hepatic arterial infusion (HAI) chemotherapy with gemcitabine (GEM) plus 5-fluorouracil (5-FU) or oral S-1 treatment for postoperative liver metastases from pancreatic cancer. Seven patients with postoperative liver metastases from pancreatic cancer received HAI with GEM plus 5-FU or oral S-1 between October, 2008 and September, 2010 at Kanazawa University Hospital (Kanazawa, Japan). Three out of the 7 cases exhibited a partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) and stable disease (SD) was achieved in 3 out of the 7 cases (response rate, 85.7%). A decrease in serum tumor marker CA 19-9 levels was observed after 10 HAI treatment cycles in 5 out of the 7 cases. The median time to treatment failure was 8 months (range, 0–17 months). Adverse events included grade 3 leukocytopenia in 1 case and anemia in all 7 cases, although 5 out of the 7 patients were anemic prior to HAI therapy. Grade 2 thrombocytopenia was also observed in 2 cases. Non-hematological events, such as nausea, diarrhea, liver injury or neuropathy and life-threatening toxicities were not reported; however, 6 patients (85.7%) developed catheter-related complications and the HAI catheter and subcutaneous implantable port system had to be removed. These findings demonstrated that HAI may deliver high doses of chemotherapeutic agents directly into the tumor vessels, producing increased regional levels with greater efficacy and a lower incidence/severity of systemic side effects. In conclusion, HAI chemotherapy is a safe and effective treatment for liver metastases from pancreatic cancer.
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Affiliation(s)
- Hidehiro Tajima
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hirohisa Kitagawa
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Tomoya Tsukada
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Koichi Okamoto
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Shin-Ichi Nakanuma
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Seisho Sakai
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Isamu Makino
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hiroyuki Furukawa
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hironori Hayashi
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Katsunobu Oyama
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Masafumi Inokuchi
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hisatoshi Nakagawara
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Tomoharu Miyashita
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hiroshi Itoh
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hideto Fujita
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Hiroyuki Takamura
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Itasu Ninomiya
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Sachio Fushida
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Takashi Fujimura
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Tetsuo Ohta
- Department of Gastroenterological Surgery and, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Wataru Koda
- Department of Radiology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Tetsuya Minami
- Department of Radiology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Yasuji Ryu
- Department of Radiology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Junichiro Sanada
- Department of Radiology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Toshifumi Gabata
- Department of Radiology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Osamu Matsui
- Department of Radiology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa 920-8641, Japan
| | - Yoshimichi Sai
- Division of Pharmacy, Kanazawa University Hospital, Kanazawa, Ishikawa 920-8641, Japan
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Kimura J, Ono HA, Kosaka T, Nagashima Y, Hirai S, Ohno S, Aoki K, Julia D, Yamamoto M, Kunisaki C, Endo I. Conditionally replicative adenoviral vectors for imaging the effect of chemotherapy on pancreatic cancer cells. Cancer Sci 2013; 104:1083-90. [PMID: 23679574 DOI: 10.1111/cas.12196] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 05/01/2013] [Accepted: 05/03/2013] [Indexed: 12/26/2022] Open
Abstract
Pancreatic cancer has a poor prognosis after complete macroscopic resection combined with chemotherapy. Even after neoadjuvant chemotherapy, R0 resection is often not possible. Moreover, current imaging techniques cannot reliably distinguish viable cancer cells from scar tissue at the resectional margin. We investigated the use of a conditionally replicative adenovirus (CRAd), Ad5/3Cox2CRAd-ΔE3ADP-Luc, for imaging the effects of chemotherapy. The CRAd infectivity of pancreatic cancer cells was enhanced by a chimeric Ad5/3 fiber, E1A expression was under the control of the Cox2 promoter, and the luciferase gene was inserted adjacent to the adenovirus death protein (ADP) gene. Subcutaneous xenografts of the pancreatic cancer cell line MiaPaCa-2 were established in 24 BALB/c nu/nu mice. When xenografts reached a diameter of 4-6 mm (day 1), the mice were injected i.p. with either PBS (group A; n = 12) or 1000 mg/kg gemcitabine (group B; n = 12), weekly. On days 19, 26, 33, and 40, CRAd were injected intratumorally into three mice in groups A and B. Bioluminescence was imaged 72 h after CRAd injection, and gross tumor volumes were measured then tumors were removed for ex vivo histopathology using H&E and Ki-67 staining. Correlations between gross tumor volume, pathological evaluation of the percentage of viable tumor area, and CRAd bioluminescence were analyzed. Bioluminescence correlated closely with the percentage of viable tumor area (R = 0.96), but not with gross tumor volume (R = 0.31). Therefore, CRAds might be reliable imaging tools for monitoring chemotherapy in pancreatic cancer, and could improve our ability to distinguish viable tumor cells from scar tissue.
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Affiliation(s)
- Jun Kimura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama-city University, Yokohama, Japan
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Sahora K, Schindl M, Kuehrer I, Werba G, Fitzal F, Goetzinger P, Gnant M. Gemcitabine-based neoadjuvant chemotherapy for locally advanced pancreatic cancer does not affect mortality and morbidity after pancreatic resection. Eur Surg 2013. [DOI: 10.1007/s10353-013-0213-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Kittaka H, Takahashi H, Ohigashi H, Gotoh K, Yamada T, Tomita Y, Hasegawa Y, Yano M, Ishikawa O. Role of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in predicting the pathologic response to preoperative chemoradiation therapy in patients with resectable T3 pancreatic cancer. World J Surg 2013; 37:169-78. [PMID: 22955953 DOI: 10.1007/s00268-012-1775-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate whether (18)F-fluorodeoxyglucose positron emission tomography in combination with computed tomography (FDG-PET/CT) could correctly predict the pathologic response to preoperative chemoradiation therapy (CRT) for resectable pancreatic cancer. METHODS Each of the 40 patients underwent FDG-PET/CT before and after preoperative CRT. The maximum standard uptake value (SUV) was measured for the primary tumor before and after preoperative CRT, defined as pre-CRT SUV and post-CRT SUV, respectively. The proportional alteration of the SUV decline (regression index) between post-CRT SUV and pre-CRT SUV was also calculated. These three indicators were associated with the pathologic response. RESULTS Patients were classified as 21 responders and 19 nonresponders according to the histologic features. A pre-CRT SUV ≥ 4.7 was seen in 15 (71 %) of 21 responders and in 6 (32 %) of 19 nonresponders (p = 0.03). A regression index ≥ 0.46 was seen in 15 (71 %) responders and 5 (26 %) nonresponders (p = 0.01). CONCLUSIONS A better pathological response can be expected for pancreatic cancer patients who have a high regression index (≥ 0.46) and a high pre-CRT SUV (≥ 4.7). The SUV measurement using FDG-PET/CT is a useful tool for predicting the pathologic response to preoperative CRT.
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Affiliation(s)
- Hirotada Kittaka
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan.
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Calvo F, Guillen Ponce C, Muñoz Beltran M, Sanjuanbenito Dehesa A. Multidisciplinary management of locally advanced–borderline resectable adenocarcinoma of the head of the pancreas. Clin Transl Oncol 2012. [DOI: 10.1007/s12094-012-0962-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Wang F, Kumar P. The role of radiotherapy in management of pancreatic cancer. J Gastrointest Oncol 2012; 2:157-67. [PMID: 22811846 DOI: 10.3978/j.issn.2078-6891.2011.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 07/26/2011] [Indexed: 12/14/2022] Open
Abstract
Pancreatic cancer is one of the leading causes of cancer death. The treatment options in pancreatic cancer remain limited. This review provides an overview of the role of radiotherapy (RT) alone or in combination with systemic treatment at different settings of treatment strategy. Neoadjuvant chemoradiotherapy (CRT) may downstage the borderline resectable disease and make resection possible, which could translate to a survival benefit. Although the benefit of adjuvant CRT remains controversial due to inconsistent outcome of randomized trials, in North America it is still a common recommendation of the treatment. For locally advanced pancreatic cancer, the treatment option could either be chemotherapy or chemoradiotherapy. By using advanced radiotherapy modalities, the toxicity of RT could be reduced and RT dose escalation becomes possible to improve locoregional control.
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Affiliation(s)
- Fen Wang
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
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Kimple RJ, Russo S, Monjazeb A, Blackstock AW. The role of chemoradiation for patients with resectable or potentially resectable pancreatic cancer. Expert Rev Anticancer Ther 2012; 12:469-80. [PMID: 22500684 DOI: 10.1586/era.12.18] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Conflicting data and substantial controversy exist regarding optimal adjuvant treatment for those patients with resectable or potentially resectable adenocarcinoma of the pancreas. Despite improvements in short-term surgical outcomes, the use of newer chemotherapeutic agents, development of targeted agents and more precise delivery of radiation, the 5-year survival rates for early-stage patients remains less than 25%. This article critically reviews the existing data for various adjuvant treatment approaches for patients with surgically resectable pancreatic cancer. Our review confirms that despite several randomized clinical trials, the optimal adjuvant treatment approach for these patients remains unclear.
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Affiliation(s)
- Randall J Kimple
- Department of Human Oncology, University of Wisconsin, Madison, WI, USA
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40
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Hsu CC, Wolfgang CL, Laheru DA, Pawlik TM, Swartz MJ, Winter JM, Robinson R, Edil BH, Narang AK, Choti MA, Hruban RH, Cameron JL, Schulick RD, Herman JM. Early mortality risk score: identification of poor outcomes following upfront surgery for resectable pancreatic cancer. J Gastrointest Surg 2012; 16:753-61. [PMID: 22311282 PMCID: PMC3561732 DOI: 10.1007/s11605-011-1811-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 12/28/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Identifying pancreatic cancer patients at high risk of early mortality following pancreaticoduodenectomy (PD) is important for treatment decisions in a multidisciplinary setting. This study examines the preoperative predictors of early mortality following PD and combines these variables into an early mortality risk score (EMRS). METHODS Medical records of patients who underwent PD for pancreatic adenocarcinoma at the Johns Hopkins Hospital between 30 August 1993 and 28 February 2005 were reviewed. Cox proportional hazards analysis was performed to identify predictors of early mortality, defined as death at 9 and 12 months. EMRS was constructed from univariate associated risk factors (age >75 years, tumor size ≥ 3 cm, poor differentiation, co-morbid diseases) with each factor assigned 1 point (range of 0-4). EMRS was evaluated as an independent predictor of death at 9 and 12 months. RESULTS On univariate analysis, risk factors for death at 9 months included age ≥ 75 years (RR, 1.6; p = .009), comorbid disease (RR, 1.5; p = 0.020), tumor ≥ 3 cm (RR, 1.4; P = 0.050), and poor differentiation (RR, 2.1; P < 0.001). EMRS was associated with early mortality among those who did (p = 0.038) and did not receive adjuvant treatment (p < 0.001). A modified EMRS without tumor differentiation was also associated with early mortality (p < 0.001). Results persisted when reanalyzed using death at 12 months. CONCLUSIONS EMRS may identify patients at risk of early mortality following PD who may be candidates for alternatively sequenced treatment protocols. Prospective validation of this EMRS is needed.
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Affiliation(s)
- Charles C. Hsu
- The Department of Radiation Oncology and Molecular Radiation, Sciences, Johns Hopkins University School of Medicine, 410 North Broadway/Suite 1440, Baltimore, MD 21231-2410, USA. The Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher L. Wolfgang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel A. Laheru
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael J. Swartz
- The Department of Radiation Oncology and Molecular Radiation, Sciences, Johns Hopkins University School of Medicine, 410 North Broadway/Suite 1440, Baltimore, MD 21231-2410, USA
| | - Jordan M. Winter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raymond Robinson
- The Department of Radiation Oncology and Molecular Radiation, Sciences, Johns Hopkins University School of Medicine, 410 North Broadway/Suite 1440, Baltimore, MD 21231-2410, USA
| | - Barish H. Edil
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol K. Narang
- The Department of Radiation Oncology and Molecular Radiation, Sciences, Johns Hopkins University School of Medicine, 410 North Broadway/Suite 1440, Baltimore, MD 21231-2410, USA
| | - Michael A. Choti
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H. Hruban
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L. Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D. Schulick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M. Herman
- The Department of Radiation Oncology and Molecular Radiation, Sciences, Johns Hopkins University School of Medicine, 410 North Broadway/Suite 1440, Baltimore, MD 21231-2410, USA. The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Lombardi L, Troiano M, Silvestris N, Nanni L, Latiano TP, Di Maggio G, Cinieri S, Di Sebastiano P, Colucci G, Maiello E. Combined modality treatments in pancreatic cancer. Expert Opin Ther Targets 2012; 16 Suppl 2:S71-81. [PMID: 22443336 DOI: 10.1517/14728222.2012.662959] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Of all the carcinomas, pancreatic carcinoma (PC) has the highest mortality rate, with a 1- and 5-year survival rate of 25% and less than 5% respectively. This is regardless of the stage at diagnosis. AREAS COVERED In this review relevant literature assessing the evidence regarding preoperative and adjuvant chemoradiotherapy (CRT) is discussed. Furthermore, new therapeutic approaches are summarized, while the future direction regarding the multimodality approach to PC is also discussed. EXPERT OPINION The role of combined-modality therapy for PC is continuously evolving. There have been several recent developments, as well as the completion of major, multi-institutional clinical trials. One of the challenges for the busy clinician is to appreciate the variation in staging, surgical expertise, and application of either definitive CRT or neo-adjuvant CRT for local and/or borderline disease.
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Affiliation(s)
- Lucia Lombardi
- Oncology Unit, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
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Hecht JR, Farrell JJ, Senzer N, Nemunaitis J, Rosemurgy A, Chung T, Hanna N, Chang KJ, Javle M, Posner M, Waxman I, Reid A, Erickson R, Canto M, Chak A, Blatner G, Kovacevic M, Thornton M. EUS or percutaneously guided intratumoral TNFerade biologic with 5-fluorouracil and radiotherapy for first-line treatment of locally advanced pancreatic cancer: a phase I/II study. Gastrointest Endosc 2012; 75:332-8. [PMID: 22248601 PMCID: PMC4380192 DOI: 10.1016/j.gie.2011.10.007] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 10/04/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND TNFeradeBiologic (AdGVEGR.TNF.11D) is a replication-deficient adenoviral vector that expresses tumor necrosis factor-α (TNF-α) under the control of the Egr-1 promoter, which is inducible by chemotherapy and radiation. OBJECTIVE This study was conducted to determine the maximal tolerated dose of TNFeradeBiologic with standard chemoradiotherapy and preliminary activity and safety of the combination in the treatment of locally advanced pancreatic cancer (LAPC). DESIGN TNFeradeBiologic was injected into locally advanced pancreatic carcinomas by using EUS or percutaneous administration once a week for 5 weeks together with 50.4 Gy radiation and 5-fluorouracil (5-FU) 200 mg/m(2) daily over 5.5 weeks. Dose levels from 4 × 10(9) to 1 × 10(12) particle units (PU) were studied. SETTING Multicentered, academic institutions. PATIENTS Fifty patients with LAPC were treated. INTERVENTIONS Doses of TNFerade Biologic were administered to patients. MAIN OUTCOME MEASUREMENTS Toleration of TNFerade Biologic was measured through toxicity and tumor response, by using the criteria of the Response Evaluation Criteria in Solid Tumors and the World Health Organization, and was reviewed by a central radiology facility. Overall survival and progression-free survival were also measured. RESULTS Dose-limiting toxicities of pancreatitis and cholangitis were observed in 3 patients at the 1 × 10(12) PU dose, making 4 × 10(11) PU the maximum tolerated dose. One complete response, 3 partial responses, and 12 patients with stable disease were noted. Seven patients eventually went to surgery, 6 had clear margins, and 3 survived >24 months. LIMITATIONS This is a Phase 1/2 non-randomized study. CONCLUSIONS Intratumoral delivery of TNFerade Biologic by EUS with fine-needle viral injection or percutaneously, combined with chemoradiation, shows promise in the treatment of LAPC. There appeared to be better clinical outcome at the maximal tolerated dose than at lower doses. The dose of 4 ×10(11) PU TNFerade Biologic was generally well tolerated, with encouraging indications of activity, and will be tested in the randomized phase of this study. Delivery of TNFerade Biologic did not interfere with subsequent surgical resection.
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Affiliation(s)
- J Randolph Hecht
- Division of Hematology-Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
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Abstract
CONTEXT Pancreatic cancer is one of the most deadly forms of cancer (43,140 new cases per year; 36,800 deaths), and most people with pancreatic cancer do not survive past 5 years. New therapeutic regimens are constantly being evaluated in an attempt to reduce the rapid progression of this disease. Although some patients receive neoadjuvant therapy in an attempt to make a nonresectable or borderline-resectable tumor resectable, more patients with resectable disease are being enrolled in clinical trials that provide neoadjuvant therapy. This means more pancreatic resections must be evaluated for therapy effect. Histologic grading schemes for the assessment of posttherapy response have been described, but difficulties associated with determining the histologic features of treatment effect in pancreatic cancer have not been addressed. OBJECTIVES To critically review the diagnostic criteria for proposed grading schemes for pancreatic cancer treated with neoadjuvant chemoradiation therapy and to provide guidance to surgical pathologists who encounter treated pancreatic cancer resections. DATA SOURCES Published peer-reviewed literature and the personal experience of the authors. CONCLUSIONS Assessment of treatment effect in pancreatic cancer is difficult. Pathologists need to be aware that some histologic features of treatment effect overlap with histologic features seen in untreated pancreatic cancer, such as tumor cell anaplasia, necrosis, and fibrosis. Careful assessment of pancreatic resections, including detailed gross examination and thorough histologic sampling, is important in accurately assessing treatment effect and improving patient outcomes.
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Affiliation(s)
- Douglas J Hartman
- Department of Pathology, University of Pittsburgh Medical Center, Pennsylvania 15213-2546, USA.
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Estrella JS, Rashid A, Fleming JB, Katz MH, Lee JE, Wolf RA, Varadhachary GR, Pisters PWT, Abdalla EK, Vauthey JN, Wang H, Gomez HF, Evans DB, Abbruzzese JL, Wang H. Post-therapy pathologic stage and survival in patients with pancreatic ductal adenocarcinoma treated with neoadjuvant chemoradiation. Cancer 2012; 118:268-77. [PMID: 21735446 DOI: 10.1002/cncr.26243] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 03/23/2011] [Accepted: 04/13/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiation before surgery is an emerging treatment modality for pancreatic ductal adenocarcinoma (PDAC). However, analysis of prognostic factors is limited for patients with PDAC treated with neoadjuvant chemoradiation and pancreaticoduodenectomy (PD). METHODS The study population was comprised of 240 consecutive patients with PDAC who received neoadjuvant chemoradiation and PD and was compared with 60 patients who had no neoadjuvant therapy between 1999 and 2007. Clinicopathologic features were correlated with disease-free survival (DFS) and overall survival (OS). RESULTS Among the 240 treated patients, the 1-year and 3-year DFS rates were 52% and 32%, with a median DFS of 15.1 months. The 1-year and 3-year OS rates were 95% and 47%, with a median OS of 33.5 months. By univariate analysis, DFS was associated with age, post-therapy tumor stage (ypT), lymph node status (ypN), number of positive lymph nodes, and American Joint Committee on Cancer (AJCC) stage, whereas OS was associated with intraoperative blood loss, margin status, ypT, ypN, number of positive lymph nodes, and AJCC stage. By multivariate analysis, DFS was independently associated with age, number of positive lymph nodes, and AJCC stage, and OS was independently associated with differentiation, margin status, number of positive lymph nodes, and AJCC stage. In addition, the treated patients had better OS and lower frequency of lymph node metastasis than those who had no neoadjuvant therapy. CONCLUSIONS In patients with PDAC who received neoadjuvant chemoradiation and subsequent PD, post-therapy pathologic AJCC stage and number of positive lymph nodes are independent prognostic factors.
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Affiliation(s)
- Jeannelyn S Estrella
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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Bickenbach KA, Gonen M, Tang LH, O'Reilly E, Goodman K, Brennan MF, D'Angelica MI, Dematteo RP, Fong Y, Jarnagin WR, Allen PJ. Downstaging in pancreatic cancer: a matched analysis of patients resected following systemic treatment of initially locally unresectable disease. Ann Surg Oncol 2011; 19:1663-9. [PMID: 22130621 DOI: 10.1245/s10434-011-2156-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with locally unresectable pancreatic cancer (AJCC stage III) have a median survival of 10-14 months. The objective of this study was to evaluate outcome of initially unresectable patients who respond to multimodality therapy and undergo resection. METHODS Using a prospectively collected database, patients were identified who were initially unresectable because of vascular invasion and had sufficient response to nonoperative treatment to undergo resection. Overall survival (OS) was compared with a matched group of patients who were initially resectable. Case matching was performed using a previously validated pancreatic cancer nomogram. RESULTS A total of 36 patients with initial stage III disease were identified who underwent resection after treatment with either systemic therapy or chemoradiation. Initial unresectability was determined by operative exploration (n = 15, 42%) or by cross-sectional imaging (n = 21, 58%). Resection consisted of pancreaticoduodenectomy (n = 31, 86%), distal pancreatectomy (n = 4, 11%), and total pancreatectomy (n = 1, 3%). Pathology revealed T3 lesions in 26 patients (73%), node positivity in 6 patients (16%), and a negative margin in 30 patients (83%). The median OS in this series was 25 months from resection and 30 months since treatment initiation. There was no difference in OS from time of resection between the initial stage III patients and those who presented with resectable disease (P = .35). CONCLUSIONS In this study, patients who were able to undergo resection following treatment of initial stage III pancreatic cancer experienced survival similar to those who were initially resectable. Resection is indicated in this highly select group of patients.
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Affiliation(s)
- K A Bickenbach
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY, USA
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A systematic review and meta-analysis of survival and surgical outcomes following neoadjuvant chemoradiotherapy for pancreatic cancer. J Gastrointest Surg 2011. [PMID: 21913045 DOI: 10.1007/s11605-011-1659-] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION This systematic review and meta-analysis aims to characterize the surgically important benefits and complications associated with the use of neoadjuvant chemoradiotherapy for the treatment of both resectable and initially unresectable pancreatic cancer. Studies were identified through a systematic literature search and analyzed by two independent reviewers. Survival, peri-operative complications, death rate, pancreatic fistula rate, and the incidence of involved surgical margins were analyzed and subject to meta-analysis. METHODS Nineteen studies, involving 2,148 patients were identified. Only cohort studies were included. RESULTS The meta-analysis found that patients with unresectable pancreatic cancer who underwent neoadjuvant chemoradiotherapy achieved similar survival outcomes to patients with resectable disease, even though only 40% were ultimately resected. Neoadjuvant chemoradiotherapy was not associated with a statistically significant increase in the rate of pancreatic fistula formation or total complications. CONCLUSION Patients receiving neoadjuvant chemoradiotherapy were less likely to have a positive resection margin, although there was an increase in the risk of peri-operative death.
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Laurence JM, Tran PD, Morarji K, Eslick GD, Lam VWT, Sandroussi C. A systematic review and meta-analysis of survival and surgical outcomes following neoadjuvant chemoradiotherapy for pancreatic cancer. J Gastrointest Surg 2011; 15:2059-69. [PMID: 21913045 DOI: 10.1007/s11605-011-1659-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Accepted: 08/08/2011] [Indexed: 02/06/2023]
Abstract
INTRODUCTION This systematic review and meta-analysis aims to characterize the surgically important benefits and complications associated with the use of neoadjuvant chemoradiotherapy for the treatment of both resectable and initially unresectable pancreatic cancer. Studies were identified through a systematic literature search and analyzed by two independent reviewers. Survival, peri-operative complications, death rate, pancreatic fistula rate, and the incidence of involved surgical margins were analyzed and subject to meta-analysis. METHODS Nineteen studies, involving 2,148 patients were identified. Only cohort studies were included. RESULTS The meta-analysis found that patients with unresectable pancreatic cancer who underwent neoadjuvant chemoradiotherapy achieved similar survival outcomes to patients with resectable disease, even though only 40% were ultimately resected. Neoadjuvant chemoradiotherapy was not associated with a statistically significant increase in the rate of pancreatic fistula formation or total complications. CONCLUSION Patients receiving neoadjuvant chemoradiotherapy were less likely to have a positive resection margin, although there was an increase in the risk of peri-operative death.
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Affiliation(s)
- Jerome Martin Laurence
- Department of Surgery, University of Sydney, Blackburn Building D06, Sydney, NSW, 2006, Australia.
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NeoGemTax: gemcitabine and docetaxel as neoadjuvant treatment for locally advanced nonmetastasized pancreatic cancer. World J Surg 2011; 35:1580-9. [PMID: 21523499 DOI: 10.1007/s00268-011-1113-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND About 30% of patients with pancreatic cancer suffer from locally advanced nonmetastatic carcinoma at the time of diagnosis. We conducted a prospective phase II clinical trial using neoadjuvant chemotherapy, consisting of gemcitabine and docetaxel, to assess the rate of complete radical resection and overall survival. METHODS Gemcitabine (900 mg/m2) and docetaxel (35 mg/m2) were given on days 1, 8, and 15 of a 28-day cycle. Two cycles were administered for a preoperative treatment duration of 8 weeks. Patients experiencing tumor regression or stable disease and improved performance status subsequently underwent surgical exploration and pancreatic resection, if feasible. All patients were followed postoperatively to assess long-term survival. RESULTS A total of 25 patients were eligible and included in the intent-to-treat and evaluable population. Thirteen patients had unresectable disease at inclusion and 12 patients had borderline resectable pancreatic cancer. Finally, 8 of 25 (32%) patients underwent resection after neoadjuvant chemotherapy; 7 (87%) of these patients had R0 resection. The median overall survival of patients who underwent resection was 16 months (95% confidence interval [CI], 8-24 months) compared to 12 months (95% CI, 8-16 months) for those without resection (p=0.276). The median recurrence-free survival rate after resection was 12 months (95% CI, 2-21 months). CONCLUSIONS NeoGemTax was safe and resection was feasible in a number of patients after systemic neoadjuvant treatment. Further randomized clinical trials are needed to identify novel multimodal regimens that would be able to increase the percentage of patients undergoing curative pancreatic cancer surgery despite advanced tumor stage at the time of diagnosis.
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Basu S, Srivastava V, Shukla VK. Reviewing the standard of care in pancreatic adenocarcinoma: A critical appraisal. SURGICAL PRACTICE 2011. [DOI: 10.1111/j.1744-1633.2011.00549.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Perioperative high dose rate (HDR) brachytherapy in unresectable locally advanced pancreatic tumors. J Contemp Brachytherapy 2011; 3:84-90. [PMID: 27895674 PMCID: PMC5117535 DOI: 10.5114/jcb.2011.23202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2011] [Accepted: 06/17/2011] [Indexed: 12/28/2022] Open
Abstract
Purpose The aim of the study was to present an original technique of catheter implantation for perioperative HDR-Ir192 brachytherapy in patients after palliative operations of unresectable locally advanced pancreatic tumors and to estimate the influence of perioperative HDR-Ir192 brachytherapy on pain relief in terminal pancreatic cancer patients. Material and methods Eight patients with pancreatic tumors located in the head of pancreas underwent palliative operations with the use of HDR-Ir192 brachytherapy. All patients qualified for surgery reported pain of high intensity and had received narcotic painkillers prior to operation. During the last phase of the surgery, the Nucletron® catheters were implanted in patients to prepare them for later perioperative brachytherapy. Since the 6th day after surgery HDR brachytherapy was performed. Before each brachytherapy fraction the location of implants were checked using fluoroscopy. A fractional dose was 5 Gy and a total dose was 20 Gy in the area of radiation. A comparative study of two groups of patients (with and without brachytherapy) with stage III pancreatic cancer according to the TNM scale was taken in consideration. Results and Conclusions The authors claim that the modification of catheter implantation using specially designed cannula, facilitates the process of inserting the catheter into the tumor, shortens the time needed for the procedure, and reduces the risk of complications. Mean survival time was 5.7 months. In the group of performed brachytherapy, the mean survival time was 6.7 months, while in the group of no brachytherapy performed – 4.4 months. In the group of brachytherapy, only one patient increased the dose of painkillers in the last month of his life. Remaining patients took constant doses of medicines. Perioperative HDR-Ir192 brachytherapy could be considered as a practical application of adjuvant therapy for pain relief in patients with an advanced pancreatic cancer.
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