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Muaddi H, Kearse L, Warner S. Multimodal Approaches to Patient Selection for Pancreas Cancer Surgery. Curr Oncol 2024; 31:2260-2273. [PMID: 38668070 PMCID: PMC11049254 DOI: 10.3390/curroncol31040167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
With an overall 5-year survival rate of 12%, pancreas ductal adenocarcinoma (PDAC) is an aggressive cancer that claims more than 50,000 patient lives each year in the United States alone. Even those few patients who undergo curative-intent resection with favorable pathology reports are likely to experience recurrence within the first two years after surgery and ultimately die from their cancer. We hypothesize that risk factors for these early recurrences can be identified with thorough preoperative staging, thus enabling proper patient selection for surgical resection and avoiding unnecessary harm. Herein, we review evidence supporting multidisciplinary and multimodality staging, comprehensive neoadjuvant treatment strategies, and optimal patient selection for curative-intent surgical resections. We further review data generated from our standardized approach at the Mayo Clinic and extrapolate to inform potential future investigations.
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Affiliation(s)
| | | | - Susanne Warner
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN 55902, USA; (H.M.)
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2
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Ruff SM, Stevens L, Bressler L, Khatri R, Sarna A, Ejaz AM, Dillhoff M, Pawlik TM, Rose K, Cloyd JM. Evaluating the caregiver experience during neoadjuvant therapy for pancreatic ductal adenocarcinoma. J Surg Oncol 2024; 129:775-784. [PMID: 38063046 DOI: 10.1002/jso.27558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 11/10/2023] [Accepted: 11/25/2023] [Indexed: 02/17/2024]
Abstract
INTRODUCTION Neoadjuvant therapy (NT) is increasingly recommended for patients with localized pancreatic ductal adenocarcinoma (PDAC). Recent research has highlighted the significant treatment burden that patients experience during NT, but caregiver well-being during NT is poorly understood. METHODS A cross-sectional mixed-methods analysis of primary caregivers of patients with localized PDAC receiving NT was undertaken. All patients completed the Caregiver Quality of Life Index-Cancer (CQOLC) survey, while semi-structured interviews were conducted among a convenience sample of participants. RESULTS Among 28 caregivers, the mean age was 60.1 years, and most were patient spouses/significant others (71.4%). Patients had resectable (18%), borderline resectable (46%), or locally advanced (36%) PDAC with a mean treatment duration of 2.9 months at the time of their caregiver's enrollment. Most caregivers felt that they received adequate emotional/psychosocial support (80%) and understood the rationale for NT (93%). A majority (60%) reported that caregiving responsibilities impacted their daily lives and required a decrease in their work hours, leading to financial challenges (47%). While overall QOL was moderate (mean 83 ± 21.1, range 0-140), "emotional burden" (47.3 ± 20.9), and "positive adaption" (57.3 ± 13.9) were the lowest ranked CQOLC subsection scores. DISCUSSION Caregivers of patients with PDAC undergoing NT experience significant emotional symptoms and impact on their daily lives. Assessing caregiver needs and providing resources during NT should be a priority.
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Affiliation(s)
- Samantha M Ruff
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Lena Stevens
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Luke Bressler
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Rakhsha Khatri
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Angela Sarna
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Aslam M Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Karen Rose
- College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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3
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Yang SQ, Zou RQ, Dai YS, Li FY, Hu HJ. Comparison of the upfront surgery and neoadjuvant therapy in resectable and borderline resectable pancreatic cancer: an updated systematic review and meta-analysis. Updates Surg 2024; 76:1-15. [PMID: 37639177 DOI: 10.1007/s13304-023-01626-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023]
Abstract
Pancreatic cancer is a malignant disease with a dismal prognosis. While neoadjuvant therapy has shown promise in the treatment of pancreatic cancer, its role remains a subject of controversy among physicians. We aimed to evaluate the benefits of neoadjuvant therapy in patients with resectable and borderline resectable pancreatic cancer. Eligible studies were identified from MEDLINE, Embase, Cochrane Library, and Web of Science. Studies comparing neoadjuvant therapy with upfront surgery (with or without adjuvant therapy) in resectable and borderline resectable pancreatic cancer were included. The primary endpoint assessed was overall survival. A total of 10,022 studies were identified, and the meta-analysis finally enrolled 50 revealed studies. The meta-analysis suggested that neoadjuvant therapy significantly improved the overall survival (HR 0.74, p < 0.001) and recurrence-free survival (HR 0.75, p = 0.006) compared to the upfront surgery approach. Furthermore, neoadjuvant therapy leads to favorable postoperative outcomes, with an enhanced R0 resection rate (OR 1.90, p < 0.001) and reduced lymph node metastasis (OR 0.36, p < 0.001) and perineural invasion (OR 0.42, p < 0.001), although it is associated with a reduced resection rate (OR 0.42, p < 0.001). In addition, patients treated with neoadjuvant therapy experience superior survival benefits compared to those undergoing adjuvant therapy (HR 0.87, p = 0.019). These results are further corroborated by the subgroup analysis of randomized controlled trials. Neoadjuvant therapy has the potential to provide survival benefits and improve postoperative long-term outcomes for patients with resectable and borderline resectable pancreatic cancer. However, to validate and reinforce these findings, further well-designed and large trials are required.
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Affiliation(s)
- Si-Qi Yang
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Rui-Qi Zou
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yu-Shi Dai
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Fu-Yu Li
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
| | - Hai-Jie Hu
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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Gordon JW, Chen HY, Nickles T, Lee PM, Bok R, Ohliger MA, Okamoto K, Ko AH, Larson PEZ, Wang ZJ. Hyperpolarized 13 C Metabolic MRI of Patients with Pancreatic Ductal Adenocarcinoma. J Magn Reson Imaging 2023:10.1002/jmri.29162. [PMID: 38041836 PMCID: PMC11144260 DOI: 10.1002/jmri.29162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDA) is the third leading cause of cancer-related death in the United States. However, early response assessment using the current approach of measuring changes in tumor size on computed tomography (CT) or MRI is challenging. PURPOSE To investigate the feasibility of hyperpolarized (HP) [1-13 C]pyruvate MRI to quantify metabolism in the normal appearing pancreas and PDA, and to assess changes in PDA metabolism following systemic chemotherapy. STUDY TYPE Prospective. SUBJECTS Six patients (65.0 ± 7.6 years, 2 females) with locally advanced or metastatic PDA enrolled prior to starting a new line of systemic chemotherapy. FIELD STRENGTH/SEQUENCE 3-T, T1-weighted gradient echo, metabolite-selective 13 C echoplanar imaging. ASSESSMENT Time-resolved HP [1-13 C]pyruvate data were acquired before (N = 6) and 4-weeks after (N = 3) treatment initiation. Pyruvate metabolism, as quantified by pharmacokinetic modeling and metabolite area-under-the-curve ratios, was assessed in manually segmented PDA and normal appearing pancreas ROIs (N = 5). The change in tumor metabolism before and 4-weeks after treatment initiation was assessed in primary PDA (N = 2) and liver metastases (N = 1), and was compared to objective tumor response defined by response evaluation criteria in solid tumors (RECIST) on subsequent CTs. STATISTICAL TESTS Descriptive tests (mean ± standard deviation), model fit error for pharmacokinetic rate constants. RESULTS Primary PDA showed reduced alanine-to-lactate ratios when compared to normal pancreas, due to increased lactate-to-pyruvate or reduced alanine-to-pyruvate ratios. Of the three patients who received HP [1-13 C]pyruvate MRI before and 4-weeks after treatment initiation, one patient had a primary tumor with early metabolic response (increase in alanine-to-lactate) and subsequent partial response according to RECIST, one patient had a primary tumor with relatively stable metabolism and subsequent stable disease by RECIST, and one patient had metastatic PDA with increase in lactate-to-pyruvate of the liver metastases and corresponding progressive disease according to RECIST. DATA CONCLUSION Altered pyruvate metabolism with increased lactate or reduced alanine was observed in the primary tumor. Early metabolic response assessed at 4-weeks after treatment initiation correlated with subsequent objective tumor response assessed using RECIST. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Jeremy W Gordon
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Hsin-Yu Chen
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Tanner Nickles
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Philip M Lee
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Robert Bok
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Michael A Ohliger
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Kimberly Okamoto
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Andrew H Ko
- Department of Medicine, University of California, San Francisco, California, USA
| | - Peder E Z Larson
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
- UC Berkeley-UCSF Graduate Program in Bioengineering, San Francisco, California, USA
| | - Zhen J Wang
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
- UC Berkeley-UCSF Graduate Program in Bioengineering, San Francisco, California, USA
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5
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Karbhari A, Mosessian S, Trivedi KH, Valla F, Jacobson M, Truty MJ, Patnam NG, Simeone DM, Zan E, Brennan T, Chen H, Kuo PH, Herrmann K, Goenka AH. Gallium-68-labeled fibroblast activation protein inhibitor-46 PET in patients with resectable or borderline resectable pancreatic ductal adenocarcinoma: A phase 2, multicenter, single arm, open label non-randomized study protocol. PLoS One 2023; 18:e0294564. [PMID: 38011131 PMCID: PMC10681241 DOI: 10.1371/journal.pone.0294564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/20/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease prone to widespread metastatic dissemination and characterized by a desmoplastic stroma that contributes to poor outcomes. Fibroblast activation protein (FAP)-expressing Cancer-Associated Fibroblasts (CAFs) are crucial components of the tumor stroma, influencing carcinogenesis, fibrosis, tumor growth, metastases, and treatment resistance. Non-invasive tools to profile CAF identity and function are essential for overcoming CAF-mediated therapy resistance, developing innovative targeted therapies, and improved patient outcomes. We present the design of a multicenter phase 2 study (clinicaltrials.gov identifier NCT05262855) of [68Ga]FAPI-46 PET to image FAP-expressing CAFs in resectable or borderline resectable PDAC. METHODS We will enroll up to 60 adult treatment-naïve patients with confirmed PDAC. These patients will be eligible for curative surgical resection, either without prior treatment (Cohort 1) or after neoadjuvant therapy (NAT) (Cohort 2). A baseline PET scan will be conducted from the vertex to mid-thighs approximately 15 minutes after administering 5 mCi (±2) of [68Ga]FAPI-46 intravenously. Cohort 2 patients will undergo an additional PET after completing NAT but before surgery. Histopathology and FAP immunohistochemistry (IHC) of initial diagnostic biopsy and resected tumor samples will serve as the truth standards. Primary objective is to assess the sensitivity, specificity, and accuracy of [68Ga]FAPI-46 PET for detecting FAP-expressing CAFs. Secondary objectives will assess predictive values and safety profile validation. Exploratory objectives are comparison of diagnostic performance of [68Ga]FAPI-46 PET to standard-of-care imaging, and comparison of pre- versus post-NAT [68Ga]FAPI-46 PET in Cohort 2. CONCLUSION To facilitate the clinical translation of [68Ga]FAPI-46 in PDAC, the current study seeks to implement a coherent strategy to mitigate risks and increase the probability of meeting FDA requirements and stakeholder expectations. The findings from this study could potentially serve as a foundation for a New Drug Application to the FDA. TRIAL REGISTRATION @ClinicalTrials.gov identifier NCT05262855.
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Affiliation(s)
- Aashna Karbhari
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Sherly Mosessian
- Clinical Development, Sofie Biosciences, Dulles, Virginia, United States of America
| | - Kamaxi H. Trivedi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Frank Valla
- Radiopharmaceutical and Contract Manufacturing, Sofie Biosciences, Dulles, Virginia, United States of America
| | - Mark Jacobson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Mark J. Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Nandakumar G. Patnam
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Diane M. Simeone
- Departments of Surgery and Pathology, NYU Langone Health, New York, New York, United States of America
| | - Elcin Zan
- Department of Radiology, Weill Cornell Medicine, New York, New York, United States of America
| | - Tracy Brennan
- Discovery Life Sciences, Newtown, Pennsylvania, United States of America
| | - Hongli Chen
- Discovery Life Sciences, Newtown, Pennsylvania, United States of America
| | - Phillip H. Kuo
- Departments of Medical Imaging, Medicine and Biomedical Engineering, University of Arizona, Tucson, Arizona, United States of America
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ajit H. Goenka
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
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6
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Saha A, Wadsley J, Sirohi B, Goody R, Anthony A, Perumal K, Ulahanan D, Collinson F. Can Concurrent Chemoradiotherapy Add Meaningful Benefit in Addition to Induction Chemotherapy in the Management of Borderline Resectable and Locally Advanced Pancreatic Cancer?: A Systematic Review. Pancreas 2023; 52:e7-e20. [PMID: 37378896 DOI: 10.1097/mpa.0000000000002215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVES The role of concomitant chemoradiotherapy or radiotherapy (RT) after induction chemotherapy (IC) in borderline resectable and locally advanced pancreatic ductal adenocarcinoma is debatable. This systematic review aimed to explore this. METHODS We searched PubMed, MEDLINE, EMBASE, and Cochrane database. Studies were selected reporting outcomes on resection rate, R0 resection, pathological response, radiological response, progression-free survival, overall survival, local control, morbidity, and mortality. RESULTS The search resulted in 6635 articles. After 2 rounds of screening, 34 publications were selected. We found 3 randomized controlled studies and 1 prospective cohort study, and the rest were retrospective studies. There is consistent evidence that addition of concomitant chemoradiotherapy or RT after IC improves pathological response and local control. There are conflicting results in terms of other outcomes. CONCLUSIONS Concomitant chemoradiotherapy or RT after IC improves local control and pathological response in borderline resectable and locally advanced pancreatic ductal adenocarcinoma. The role of modern RT in improving other outcome requires further research.
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Affiliation(s)
- Animesh Saha
- From the Department of Radiation Oncology, Apollo Multispecilty Hospitals, Kolkata, India
| | - Jonathan Wadsley
- Department of Clinical Oncology, Weston Park Cancer Centre, Sheffield, United Kingdom
| | - Bhawna Sirohi
- Department of Medical Oncology, Apollo Proton Cancer Centre, Chennai, India
| | | | - Alan Anthony
- Medical Oncology, Leeds Cancer Center, Leeds, United Kingdom
| | | | - Danny Ulahanan
- Medical Oncology, Leeds Cancer Center, Leeds, United Kingdom
| | - Fiona Collinson
- Medical Oncology, Leeds Cancer Center, Leeds, United Kingdom
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Choi MH, Yoon SB. Sarcopenia in pancreatic cancer: Effect on patient outcomes. World J Gastrointest Oncol 2022; 14:2302-2312. [PMID: 36568942 PMCID: PMC9782618 DOI: 10.4251/wjgo.v14.i12.2302] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/29/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cancer is a challenging disease with an increasing incidence and extremely poor prognosis. The clinical outcomes of pancreatic cancer depend on tumor biology, responses to treatments, and malnutrition or cachexia. Sarcopenia represents a severe catabolic condition defined by the age-related loss of muscle mass and strength and affects as much as 70% of malnourished pancreatic cancer patients. The lumbar skeletal muscle index, defined as the total abdominal muscle area at the L3 vertebral level adjusted by the square of the height, is widely used for assessing sarcopenia in patients with pancreatic cancer. Several studies have suggested that sarcopenia may be a risk factor for perioperative complications and decreased recurrence-free or overall survival in patients with pancreatic cancer undergoing surgery. Sarcopenia could also intensify chemotherapy-induced toxicities and worsen the quality of life and survival in the neoadjuvant or palliative chemotherapy setting. Sarcopenia, not only at the time of diagnosis but also during treatment, decreases survival in patients with pancreatic cancer. Theoretically, multimodal interventions may improve sarcopenia and clinical outcomes; however, no study has reported positive results. Further prospective studies are needed to confirm the prognostic role of sarcopenia and the effects of multimodal interventions in patients with pancreatic cancer.
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Affiliation(s)
- Moon Hyung Choi
- Department of Radiology, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, South Korea
| | - Seung Bae Yoon
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 03312, South Korea
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8
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O'Shea AE, Carpenter EL, Nelson DW, Vreeland TJ. ASO Author Reflections: The Impact on Survival of Downstaging by Neoadjuvant Chemotherapy or Chemoradiotherapy in Pancreatic Adenocarcinoma. Ann Surg Oncol 2022; 29:6029-6030. [PMID: 35583695 DOI: 10.1245/s10434-022-11878-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 04/24/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Anne E O'Shea
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA.
| | | | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Timothy J Vreeland
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
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9
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O'Shea AE, Bohan PMK, Carpenter EL, McCarthy PM, Adams AM, Chick RC, Bader JO, Krell RW, Peoples GE, Clifton GT, Nelson DW, Vreeland TJ. Downstaging of Pancreatic Adenocarcinoma With Either Neoadjuvant Chemotherapy or Chemoradiotherapy Improves Survival. Ann Surg Oncol 2022; 29:6015-6028. [PMID: 35583691 DOI: 10.1245/s10434-022-11800-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 04/05/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) or chemoradiation (NAC+XRT) is incorporated into the treatment of localized pancreatic adenocarcinoma (PDAC), often with the goal of downstaging before resection. However, the effect of downstaging on overall survival, particularly the differential effects of NAC and NAC+XRT, remains undefined. This study examined the impact of downstaging from NAC and NAC+XRT on overall survival. METHODS The National Cancer Data Base (NCDB) was queried from 2006 to 2015 for patients with non-metastatic PDAC who received NAC or NAC+XRT. Rates of overall and nodal downstaging, and pathologic complete response (pCR) were assessed. Predictors of downstaging were evaluated using multivariable logistic regression. Overall survival (OS) was assessed with Kaplan-Meier and Cox proportional hazards modeling. RESULTS The study enrolled 2475 patients (975 NAC and 1500 NAC+XRT patients). Compared with NAC, NAC+XRT was associated with higher rates of overall downstaging (38.3 % vs 23.6 %; p ≤ 0.001), nodal downstaging (16.0 % vs 7.8 %; p ≤ 0.001), and pCR (1.7 % vs 0.7 %; p = 0.041). Receipt of NAC+XRT was independently predictive of overall (odds ratio [OR] 2.28; p < 0.001) and nodal (OR 3.09; p < 0.001) downstaging. Downstaging by either method was associated with improved 5-year OS (30.5 vs 25.2 months; p ≤ 0.001). Downstaging with NAC was associated with an 8-month increase in median OS (33.7 vs 25.6 months; p = 0.005), and downstaging by NAC+XRT was associated with a 5-month increase in median OS (30.0 vs 25.0 months; p = 0.008). Cox regression showed an association of overall downstaging with an 18 % reduction in the risk of death (hazard ratio [HR] 0.82; 95 % confidence interval, 0.71-0.95; p = 0.01) CONCLUSION: Downstaging after neoadjuvant therapies improves survival. The addition of radiation therapy may increase the rate of downstaging without affecting overall oncologic outcomes.
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Affiliation(s)
- Anne E O'Shea
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA.
| | | | | | - Patrick M McCarthy
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Robert C Chick
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Julia O Bader
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Robert W Krell
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | | | - Guy T Clifton
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Timothy J Vreeland
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
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10
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Kudo M, Ishii G, Gotohda N, Konishi M, Takahashi S, Kobayashi S, Sugimoto M, Martin JD, Cabral H, Kojima M. Histological tumor necrosis in pancreatic cancer after neoadjuvant therapy. Oncol Rep 2022; 48:121. [PMID: 35583018 PMCID: PMC9164264 DOI: 10.3892/or.2022.8332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/06/2022] [Indexed: 11/06/2022] Open
Abstract
The pathological prognostic factors in pancreatic cancer patients who have received neoadjuvant therapy (NAT) are still elusive. The aim of the present study was to investigate the prognostic potential of histological tumor necrosis (HTN) in patients who received NAT and to evaluate tumor changes after NAT. HTN was studied in 44 pancreatic cancer patients who received NAT followed by surgery (NAT group) compared with 263 patients who received upfront surgery (UFS group). The prognostic factors in the NAT group were analyzed, and carbonic anhydrase 9 (CA‑9) expression was compared between the NAT and USF group to evaluate the hypoxic microenvironment changes during NAT. HTN was found in 15 of 44 patients in the NAT group, and its frequency was lower than that in the UFS group (34 vs. 51%, P=0.04). Cox proportional hazards models identified HTN as an independent risk factor for relapse‑free survival in the NAT group [risk ratio (RR), 5.60; 95% confidence interval (CI): 2.27‑14.26, P<0.01]. Significant correlations were found between HTN and CA‑9 expression both in the NAT and UFS groups (P<0.01 for both). CA‑9 expression was significantly upregulated in the NAT group overall, although this upregulation was specifically induced in patients without HTN. In conclusion, HTN was a poor prognostic factor in pancreatic cancer patients receiving NAT followed by surgery, and the present study suggests a close association between HTN and tumor hypoxia. Increased hypoxia after NAT may support the thesis for re‑engineering the hypoxia‑alleviating tumor microenvironment in NAT regimens for pancreatic cancer.
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Affiliation(s)
- Masashi Kudo
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Chiba 277-8577, Japan
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | - Genichiro Ishii
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Chiba 277-8577, Japan
| | - Naoto Gotohda
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | - Masaru Konishi
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | - Shinichiro Takahashi
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
- Clinical Research Support Office, National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | - Shin Kobayashi
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | - Motokazu Sugimoto
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan
| | | | - Horacio Cabral
- Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, Tokyo 113-8656, Japan
| | - Motohiro Kojima
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Chiba 277-8577, Japan
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11
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Narayanan S, Paniccia A. Response to "Prognostic factors in patients with pancreatic ductal adenocarcinoma with neoadjuvant treatment and pancreatectomy". J Surg Oncol 2022; 125:1072. [PMID: 35267193 DOI: 10.1002/jso.26853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Sowmya Narayanan
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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12
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Gugenheim J, Crovetto A, Petrucciani N. Neoadjuvant therapy for pancreatic cancer. Updates Surg 2022; 74:35-42. [PMID: 34628591 PMCID: PMC8502083 DOI: 10.1007/s13304-021-01186-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/30/2021] [Indexed: 12/12/2022]
Abstract
Multimodal treatment including surgery and chemotherapy is considered the gold standard treatment of pancreatic cancer by most guidelines. Neoadjuvant therapy (NAT) has been seen as a possible treatment option for resectable, borderline resectable and locally advanced PaC. The aim of this paper is to offer a state-of-the-art review on neoadjuvant treatments in the setting of pancreatic ductal adenocarcinoma. A systematic literature search was performed using PubMed, Cochrane, Web of Science and Embase databases, in order to identify relevant studies published up to and including July 2021 that reported and analyzed the role of neoadjuvant therapy in the setting of pancreatic carcinoma. Most authors are concordant on the strong role of neoadjuvant therapy in the setting of borderline resectable pancreatic cancers. Recent randomized trials demonstrated improvement of R0 rate and survival after NAT in this setting. Patients with locally advanced cancers may become resectable after NAT, with better results than those obtained with palliative therapies. Even in the setting of resectable cancers, NAT is being evaluated by ongoing randomized trials. Chemotherapy regimens in the setting of NAT and response to NAT are discussed. NAT has an important role in the multimodal treatment of patients with borderline resectable pancreatic cancer. It has a role in patients with locally advanced tumors as it can allow surgical resection in a relevant proportion of patients. For resectable pancreatic cancers, the role of NAT is under evaluation by several randomized trials.
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Affiliation(s)
- Jean Gugenheim
- Université Côte d'Azur, Nice, France.
- Division of Digestive Surgery and Liver Transplantation, Archet 2 Hospital, University Hospital of Nice, 151 Route de Saint-Antoine, 06200, Nice, France.
| | - Anna Crovetto
- Faculty of Medicine and Psychology, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Niccolo Petrucciani
- Faculty of Medicine and Psychology, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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13
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Brown ZJ, Labiner HE, Shen C, Ejaz A, Pawlik TM, Cloyd JM. Impact of care fragmentation on the outcomes of patients receiving neoadjuvant and adjuvant therapy for pancreatic adenocarcinoma. J Surg Oncol 2022; 125:185-193. [PMID: 34599756 PMCID: PMC9113396 DOI: 10.1002/jso.26706] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/25/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Neoadjuvant therapy (NT) is increasingly used for localized pancreatic ductal adenocarcinoma (PDAC). The impact of care fragmentation during NT on the outcomes of patients with PDAC is unknown. METHODS Adult patients with Stage I-III PDAC who received NT and patients who underwent surgery first followed by adjuvant therapy (AT) between 2004 and 2016 were queried from the National Cancer Database. Short- and long-term outcomes were compared between patients who received fragmented care (FC; care provided at >1 hospital) versus integrated care (IC; care at a single institution). RESULTS Among 6522 patients who underwent NT before pancreatectomy, 3755 (57.6%) received FC and 2767 (42.4%) received IC. While patients who received FC had a longer time to initiation of treatment (33.2 vs. 29.7 days, p < 0.001), there was no difference in median overall survival (OS) (26.7 vs. 26.5 months, p = 0.6). Among patients who underwent upfront surgery followed by AT (n = 15 291), patients who received FC had a longer time from diagnosis to undergoing surgery but less time from surgery to AT and no difference in OS (24.0 vs. 24.0 months, p = 0.910). CONCLUSION Although care fragmentation was associated with slightly longer times to initiate and complete treatment among patients with localized PDAC, long-term survival outcomes were similar.
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Affiliation(s)
- Zachary J. Brown
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Hanna E. Labiner
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Chengli Shen
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Jordan M. Cloyd
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
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14
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Bhalla S, Zhu H, Lin J, Özbek U, Wilck EJ, Chang S, Chen X, Ward S, Harpaz N, Polydorides AD, Miller W, Fiel MI, Modica I, Fan W, Zeizafoun N, Ang C. Impact of pathological response after neoadjuvant chemotherapy on adjuvant therapy decisions and patient outcomes in gastrointestinal cancers. Cancer Rep (Hoboken) 2021; 4:e1412. [PMID: 34032391 PMCID: PMC8714550 DOI: 10.1002/cnr2.1412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/07/2021] [Accepted: 04/14/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) is frequently used in gastrointestinal cancers (GIC), and pathological, radiological, and tumor marker responses are assessed during and after NAC. AIM To evaluate the relationship between pathologic, radiologic, tumor marker responses and recurrence-free survival (RFS), overall survival (OS), adjuvant chemotherapy (AC) decisions, and the impact of changing to a different AC regimen after poor response to NAC. METHODS AND RESULTS Medical records of GIC patients treated with NAC at Mount Sinai between 1/2012 and 12/2018 were reviewed. One hundred fifty-six patients (58.3% male, mean age 63 years) were identified. Primary tumor sites were: 43 (27.7%) pancreas, 62 (39.7%) gastroesophageal, and 51 (32.7%) colorectal. After NAC, 31 (19.9%) patients had favorable pathologic response (FPR; defined as College of American Pathologists [CAP] score 0-1). Of 107 patients with radiological data, 59 (55.1%) had an objective response, and of 113 patients with tumor marker data, 61 (54.0%) had a ≥50% reduction post NAC. FPR, but not radiographic or serological responses, was associated with improved RFS (HR 0.28; 95% CI 0.11-0.72) and OS (HR 0.13; 95% CI 0.2-0.94). Changing to a different AC regimen from initial NAC, among all patients and specifically among those with unfavorable pathological response (UPR; defined as CAP score 2-3) after NAC, was not associated with improved RFS or OS. CONCLUSIONS GIC patients with FPR after NAC experienced significant improvements in RFS and OS. Patients with UPR did not benefit from changing AC. Prospective studies to better understand the role of pathological response in AC decisions and outcomes in GIC patients are needed.
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Affiliation(s)
- Sheena Bhalla
- Division of Hematology and Medical OncologyIcahn School of Medicine at Mount SinaiNew YorkUSA
| | - Huili Zhu
- Department of Internal MedicineIcahn School of Medicine at Mount SinaiNew YorkUSA
| | - Jung‐Yi Lin
- Department of Population Health Science and PolicyTisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkUSA
| | - Umut Özbek
- Department of Population Health Science and PolicyTisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkUSA
| | - Eric J. Wilck
- Department of RadiologyIcahn School of Medicine at Mount SinaiNew YorkUSA
| | - Sanders Chang
- Department of RadiologyIcahn School of Medicine at Mount SinaiNew YorkUSA
| | - Xiuxu Chen
- Department of PathologyLoyola University Medical CenterMaywoodIllinoisUSA
| | - Stephen Ward
- Department of PathologyIcahn School of Medicine at Mount SinaiNew YorkUSA
| | - Noam Harpaz
- Department of PathologyIcahn School of Medicine at Mount SinaiNew YorkUSA
| | | | - William Miller
- Department of PathologyIcahn School of Medicine at Mount SinaiNew YorkUSA
| | - Maria Isabel Fiel
- Department of PathologyIcahn School of Medicine at Mount SinaiNew YorkUSA
| | - Ippolito Modica
- Department of PathologyIcahn School of Medicine at Mount SinaiNew YorkUSA
| | - Wen Fan
- Department of PathologyIcahn School of Medicine at Mount SinaiNew YorkUSA
| | - Nebras Zeizafoun
- Department of PathologyIcahn School of Medicine at Mount SinaiNew YorkUSA
| | - Celina Ang
- Division of Hematology and Medical OncologyIcahn School of Medicine at Mount SinaiNew YorkUSA
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Neoadjuvant Treatment Strategies in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13184724. [PMID: 34572951 PMCID: PMC8469083 DOI: 10.3390/cancers13184724] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Only 10–20% of patients with newly diagnosed resectable pancreatic adenocarcinoma have potentially resectable disease. Upfront surgery is the gold standard, but it is rarely curative. After surgical extirpation of tumors, up to 80% of patients will develop cancer recurrence, and the initial relapse is metastatic in 50–70% of these patients. Adjuvant chemotherapy offers the best strategy to date to improve overall survival but faces real challenges; some patients will experience rapid disease progression within 3 months of surgery and patients who do not receive all planned cycles of chemotherapy have unfavourable oncological outcomes. The neoadjuvant approach is therefore logical but requires further investigation. This approach shows favourable trends regarding disease-free survival and overall survival but, in the absence of rigorous published phase III trials, is not validated to date. Here, we intend to provide a comprehensive analysis of the literature to provide direction for future studies. Abstract Complete surgical resection is the cornerstone of curative therapy for resectable pancreatic adenocarcinoma. Upfront surgery is the gold standard, but it is rarely curative. Neoadjuvant treatment is a logical option, as it may overcome some of the limitations of adjuvant therapy and has already shown some encouraging results. The main concern regarding neoadjuvant therapy is the risk of disease progression during chemotherapy, meaning the opportunity to undergo the intended curative surgery is missed. We reviewed all recent literature in the following areas: major surveys, retrospective studies, meta-analyses, and randomized trials. We then selected the ongoing trials that we believe are of interest in this field and report here the results of a comprehensive review of the literature. Meta-analyses and randomized trials suggest that neoadjuvant treatment has a positive effect. However, no study to date can be considered practice changing. We considered design, endpoints, inclusion criteria and results of available randomized trials. Neoadjuvant treatment appears to be at least a feasible strategy for patients with resectable pancreatic cancer.
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16
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Survival Benefit Associated With Resection of Locally Advanced Pancreatic Cancer Following Upfront FOLFIRINOX versus FOLFIRINOX Only: Multicenter Propensity Score-Matched Analysis. Ann Surg 2021; 274:729-735. [PMID: 34334641 DOI: 10.1097/sla.0000000000005120] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study compared median overall survival (OS) after resection of locally advanced pancreatic cancer (LAPC) following upfront FOLFIRINOX versus a propensity-score matched cohort of LAPC patients treated with FOLFIRINOX-only (i.e. without resection). BACKGROUND Since the introduction of FOLFIRINOX chemotherapy, increased resection rates in LAPC patients have been reported, with improved OS. Some studies have also reported promising OS with FOLFIRINOX-only treatment in LAPC. Multicenter studies assessing the survival benefit associated with resection of LAPC versus patients treated with FOLFIRINOX-only are lacking. METHODS Patients with non-progressive LAPC after 4 cycles of FOLFIRINOX treatment, both with and without resection, were included from a prospective multicenter cohort in 16 centers (April 2015-December 2019). Cox regression analysis identified predictors for OS. One-to-one propensity score matching (PSM) was used to obtain a matched cohort of patients with and without resection. These patients were compared for OS. RESULTS Overall, 293 patients with LAPC were included, of whom 89 underwent a resection. Resection was associated with improved OS (24 vs 15 months, p<0.01), as compared to patients without resection. Before PSM, resection, Charlson Comorbidity Index, and RECIST response were predictors for OS. After PSM, resection remained associated with improved OS (HR 0.344, 95% CI [0.222-0.534], p<0.01), with an OS of 24 vs 15 months, as compared to patients without resection. Resection of LAPC was associated with improved 3-year OS (31% vs 11%, p<0.01). CONCLUSION Resection of LAPC following FOLFIRINOX was associated with increased OS and 3-year survival, as compared to propensity-score matched patients treated with FOLFIRINOX-only.
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17
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Hamad A, Brown ZJ, Ejaz AM, Dillhoff M, Cloyd JM. Neoadjuvant therapy for pancreatic ductal adenocarcinoma: Opportunities for personalized cancer care. World J Gastroenterol 2021; 27:4383-4394. [PMID: 34366611 PMCID: PMC8316910 DOI: 10.3748/wjg.v27.i27.4383] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/12/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that is best treated in a multidisciplinary fashion using surgery, chemotherapy, and radiation. Adjuvant chemotherapy has shown to have a significant survival benefit in patients with resected PDAC. However, up to 50% of patients fail to receive adjuvant chemotherapy due to postoperative complications, poor patient performance status or early disease progression. In order to ensure the delivery of chemotherapy, an alternative strategy is to administer systemic treatment prior to surgery. Precision oncology refers to the application of diverse strategies to target therapies specific to characteristics of a patient’s cancer. While traditionally emphasized in selecting targeted therapies based on molecular, genetic, and radiographic biomarkers for patients with metastatic disease, the neoadjuvant setting is a prime opportunity to utilize personalized approaches. In this article, we describe the current evidence for the use of neoadjuvant therapy (NT) and highlight unique opportunities for personalized care in patients with PDAC undergoing NT.
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Affiliation(s)
- Ahmad Hamad
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43215, United States
| | - Zachary J Brown
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43215, United States
| | - Aslam M Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43215, United States
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43215, United States
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43215, United States
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18
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Cloyd JM, Shen C, Santry H, Bridges J, Dillhoff M, Ejaz A, Pawlik TM, Tsung A. Disparities in the Use of Neoadjuvant Therapy for Resectable Pancreatic Ductal Adenocarcinoma. J Natl Compr Canc Netw 2021; 18:556-563. [PMID: 32380462 DOI: 10.6004/jnccn.2019.7380] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/25/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Current guidelines support either immediate surgical resection or neoadjuvant therapy (NT) for patients with resectable pancreatic ductal adenocarcinoma (PDAC). However, which patients are selected for NT and whether disparities exist in the use of NT for PDAC are not well understood. METHODS Using the National Cancer Database from 2004 through 2016, the clinical, demographic, socioeconomic, and hospital-related characteristics of patients with stage I/II PDAC who underwent immediate surgery versus NT followed by surgery were compared. RESULTS Among 58,124 patients who underwent pancreatectomy, 8,124 (14.0%) received NT whereas 50,000 (86.0%) did not. Use of NT increased significantly throughout the study period (from 3.5% in 2004 to 26.4% in 2016). Multivariable logistic regression analysis showed that travel distance, education level, hospital facility type, clinical T stage, tumor size, and year of diagnosis were associated with increased use of NT, whereas comorbidities, uninsured/Medicaid status, South/West geography, left-sided tumor location, and increasing age were associated with immediate surgery (all P<.001). Based on logistic regression-derived interaction factors, the association between NT use and median income, education level, Midwest location, clinical T stage, and clinical N stage significantly increased over time (all P<.01). CONCLUSIONS In addition to traditional clinicopathologic factors, several demographic, socioeconomic, and hospital-related factors are associated with use of NT for PDAC. Because NT is used increasingly for PDAC, efforts to reduce disparities will be critical in improving outcomes for all patients with pancreatic cancer.
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Affiliation(s)
- Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, and the Center for Surgical Health Assessment, Research, and Policy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Chengli Shen
- Division of Surgical Oncology, Department of Surgery, and the Center for Surgical Health Assessment, Research, and Policy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Heena Santry
- Division of Surgical Oncology, Department of Surgery, and the Center for Surgical Health Assessment, Research, and Policy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John Bridges
- Division of Surgical Oncology, Department of Surgery, and the Center for Surgical Health Assessment, Research, and Policy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mary Dillhoff
- Division of Surgical Oncology, Department of Surgery, and the Center for Surgical Health Assessment, Research, and Policy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, and the Center for Surgical Health Assessment, Research, and Policy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, and the Center for Surgical Health Assessment, Research, and Policy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, and the Center for Surgical Health Assessment, Research, and Policy, The Ohio State University Wexner Medical Center, Columbus, Ohio
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19
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Rieser CJ, Narayanan S, Bahary N, Bartlett DL, Lee KK, Paniccia A, Smith K, Zureikat AH. Optimal management of patients with operable pancreatic head cancer: A Markov decision analysis. J Surg Oncol 2021; 124:801-809. [PMID: 34231222 DOI: 10.1002/jso.26589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/11/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Neoadjuvant therapy (NAT) is an emerging strategy for operable pancreatic ductal adenocarcinoma (PDAC). While NAT increases multimodal therapy completion, it risks functional decline and treatment dropout. We used decision analysis to determine optimal management of localized PDAC and consider risks faced by elderly patients. METHODS A Markov cohort decision analysis model evaluated treatment options for a 60-year-old patient with resectable PDAC: (1) upfront pancreaticoduodenectomy or (2) NAT. One-way and probabilistic sensitivity analyses were performed. A subanalysis considered the scenario of a 75-year-old patient. RESULTS For the base case, NAT offered an incremental survival gain of 4.6 months compared with SF (overall survival: 26.3 vs. 21.7 months). In one-way sensitivity analyses, findings were sensitive to recurrence-free survival for NAT patients undergoing adjuvant, probability of completing NAT, and probability of being resectable at exploration after NAT. On probabilistic analysis, NAT was favored in a majority of trials (97%) with a median survival benefit of 5.1 months. In altering the base case for the 75-year-old scenario, NAT had a survival benefit of 3.8 months. CONCLUSIONS This analysis demonstrates a significant benefit to NAT in patients with localized PDAC. This benefit persists even in the elderly cohort.
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Affiliation(s)
- Caroline J Rieser
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sowmya Narayanan
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David L Bartlett
- AHN Cancer Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth Smith
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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20
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Chopra A, Beane JD. ASO Author Reflections: Impact of Neoadjuvant Therapy on Survival After Margin-Positive Resection for Pancreatic Cancer. Ann Surg Oncol 2021; 28:7770-7771. [PMID: 34028634 DOI: 10.1245/s10434-021-10177-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Asmita Chopra
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Surgery, University of Toledo, Toledo, OH, USA
| | - Joal D Beane
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA. .,Division of Surgical Oncology, Department of Surgery, James Cancer Center, Ohio State University, Columbus, OH, 43210, USA.
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21
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Chopra A, Zenati M, Hogg ME, Zeh HJ, Bartlett DL, Bahary N, Zureikat AH, Beane JD. Impact of Neoadjuvant Therapy on Survival Following Margin-Positive Resection for Pancreatic Cancer. Ann Surg Oncol 2021; 28:7759-7769. [PMID: 34027585 DOI: 10.1245/s10434-021-10175-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/29/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION A positive microscopic margin (R1) following resection of pancreatic ductal adenocarcinoma (PDAC) can occur in up to 80% of patients and is associated with reduced survival and increased recurrence. Our aim was to characterize the impact of neoadjuvant therapy (NAT) on survival and recurrence in patients with PDAC following an R1 resection. METHODS A retrospective analysis of patients with PDAC who underwent pancreatectomy from 2008 to 2017 was performed. Patients were staged according to the American Joint Committee on Cancer 8th edition and stratified based on resection margin (R0 vs. R1) and treatment sequence (NAT vs. surgery first [SF]). Conditional survival analysis was performed using Cox regression and inverse probability weighted estimates. RESULTS Among 580 patients, 59% received NAT and 41% underwent SF. On final pathology, the NAT cohort had smaller tumors and less lymph node (LN) positivity (p < 0.05). NAT was not associated with an R1 resection (50%, p = 0.653). Compared with the R1 cohort, the R0 cohort had a higher median overall survival (OS; 39.6 vs. 22.8 months; hazard ratio [HR] 1.6, p < 0.001) and disease-free survival (DFS; 19 vs. 13 months; HR 1.35, p = 0.004). After risk adjustment, NAT was not associated with OS, regardless of margin status (R0, 95% confidence interval [CI] (-)7.31-27.07, p = 0.26; or R1, 95% CI (-)36.99-15.25, p = 0.42). However, NAT was associated with improved DFS in the R1 cohort (95% CI 1.79-11.91, p = 0.008) but not in the R0 cohort (95% CI (-)11.22-10.54, p = 0.95). CONCLUSION An R0 resection remains an important determinant of overall and disease-free survival, even when NAT is administered. For patients with an R1 resection, receipt of NAT may prolong DFS.
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Affiliation(s)
- Asmita Chopra
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mazen Zenati
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Department of Surgery, North Shore Hospital, Chicago, IL, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - David L Bartlett
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joal D Beane
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA. .,Division of Surgical Oncology, Department of Surgery, Ohio State University, James Cancer Center, Columbus, OH, USA.
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22
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Narayanan S, AlMasri S, Zenati M, Nassour I, Chopra A, Rieser C, Smith K, Oyefusi V, Daum T, Bahary N, Bartlett D, Lee K, Zureikat A, Paniccia A. Predictors of early recurrence following neoadjuvant chemotherapy and surgical resection for localized pancreatic adenocarcinoma. J Surg Oncol 2021; 124:308-316. [PMID: 33893740 DOI: 10.1002/jso.26510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/22/2021] [Accepted: 04/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Neoadjuvant chemotherapy (NAT) for pancreatic adenocarcinoma (PDAC) is increasingly being utilized. However, a significant number of patients will experience early recurrence, possibly negating the benefit of surgery. We aimed to identify factors implicated in early disease recurrence. METHODS A retrospective review of pancreaticoduodenectomies performed between 2005 and 2017 at our institution for PDAC following NAT was performed. A 6-month cut-off was used to stratify patients into early/late recurrence groups. Multivariate analysis was performed to identify predictors of recurrence. RESULTS Of 273 patients, 64 (23%) developed early recurrence or died within 90 days of surgery. The median time to recurrence was 4 months (95% confidence interval [CI]: 2.2-4.3) in the early group versus 16 months (95% CI: 13.7-19.9) in the late group. The former had higher baseline and post-NAT Ca19-9 levels than the latter (472 vs. 153 IU/ml, p = 0.001 and 71 vs. 39 IU/ml, p = 0.005, respectively). A higher positive lymph node ratio significantly increased the risk of early recurrence (hazard ratio [HR]: 15.9, p < 0.001) while adjuvant chemotherapy was protective (HR: 0.4, p < 0.001). CONCLUSION Our findings acknowledge the limitations of clinically measured factors used to ascertain response to NAT and underline the need for individualized molecular markers that take into consideration the specific tumor biology.
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Affiliation(s)
- Sowmya Narayanan
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samer AlMasri
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mazen Zenati
- Department of Surgery and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Nassour
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Asmita Chopra
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Caroline Rieser
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Katelyn Smith
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vivianne Oyefusi
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tracy Daum
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nathan Bahary
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David Bartlett
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth Lee
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amer Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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23
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Kurata Y, Shiraki T, Ichinose M, Kubota K, Imai Y. Effect and limitation of neoadjuvant chemotherapy for pancreatic ductal adenocarcinoma: consideration from a new perspective. World J Surg Oncol 2021; 19:85. [PMID: 33752677 PMCID: PMC7986386 DOI: 10.1186/s12957-021-02192-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/09/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Effect of neoadjuvant chemotherapy (NAC) for pancreatic ductal adenocarcinoma (PDAC) has remained under investigation. We investigated its effect from a unique perspective and discussed its application. PATIENTS AND METHODS We retrospecively analyzed consecutive 131 PDAC patients who underwent pancreatoduodenectomy and distal pancreatectomy. Clinicopathologic data at surgery and postoperative prognosis were compared between patients who underwent upfront surgery (UFS) (n = 64) and those who received NAC (n = 67), of which 62 (92.5%) received gemcitabine plus S-1 (GS). The GS regimen resulted in about 15% of partial response and 85% of stable disease in a previous study which analyzed a subset of this study subjects. RESULTS Tumor size was marginally smaller, degree of nodal metastasis and rate of distant metastasis were significantly lower, and pathologic stage was significantly lower in the NAC group than in the UFS group. In contrast, significant differences were not observed in histopathologic features such as vessel and perineural invasions and differentiation grade. Notably, disease-free and overall survivals were similar between the two groups adjusted for the pathologic stage, suggesting that effects of NAC, including macroscopically undetectable ones such as control of micro-metastasis and devitalizing tumor cells, may not be remarkable in the majority of PDAC, at least with respect to the GS regimen. CONCLUSIONS NAC may be useful in downstaging and improving prognosis in a small subset of tumors. However, postoperative prognosis may be determined at the pathologic stage of resected specimen with or without NAC. Therefore, NAC may be applicable to borderline resectable and locally advanced PDAC for enabling surgical resection, but UFS would be desirable for primary resectable PDAC.
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Affiliation(s)
- Yoshihiro Kurata
- Department of Surgery, Chiba University Hospital, Chiba, Japan.,Department of Surgery, Shioya Hospital, International University of Health and Welfare, Tochigi, Japan
| | - Takayuki Shiraki
- Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Masanori Ichinose
- Department of Surgery, Shioya Hospital, International University of Health and Welfare, Tochigi, Japan
| | - Keiichi Kubota
- Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Yasuo Imai
- Department of Diagnostic Pathology, Ota Memorial Hospital, SUBARU Health Insurance Society, 455-1 Oshima, Gunma, 373-8585, Japan.
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Navez J, Bouchart C, Lorenzo D, Bali MA, Closset J, van Laethem JL. What Should Guide the Performance of Venous Resection During Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma with Venous Contact? Ann Surg Oncol 2021; 28:6211-6222. [PMID: 33479866 PMCID: PMC8460578 DOI: 10.1245/s10434-020-09568-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/26/2020] [Indexed: 12/11/2022]
Abstract
Complete surgical resection, most often associated with perioperative chemotherapy, is the only way to offer a chance of cure for patients with pancreatic cancer. One of the most important factors in determining survival outcome that can be influenced by the surgeon is the R0 resection. However, the proximity of mesenteric vessels in cephalic pancreatic tumors, especially the mesenterico-portal venous axis, results in an increased risk of vein involvement and/or the presence of malignant cells in the venous bed margin. A concomitant venous resection can be performed to decrease the risk of a positive margin. Given the additional technical difficulty that this implies, many surgeons seek a path between the tumor and the vein, hoping for the absence of tumor infiltration into the perivascular tissue on pathologic analysis, particularly in cases with administration of neoadjuvant therapy. The definition of optimal surgical margin remains a subject of debate, but at least 1 mm is an independent predictor of survival after pancreatic cancer surgical resection. Although preoperative radiologic assessment is essential for accurate planning of a pancreatic resection, intraoperative decision-making with regard to resection of the mesenterico-portal vein in tumors with a venous contact remains unclear and variable. Although venous histologic involvement and perivascular infiltration are not accurately predictable preoperatively, clinicians must examine the existing criteria and normograms to guide their surgical management according to the integration of new imaging techniques, preoperative chemotherapy use, tumor biology and molecular histopathology, and surgical techniques.
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Affiliation(s)
- Julie Navez
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Diane Lorenzo
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Jean Closset
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Luc van Laethem
- Medico-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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25
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Watson MD, Baimas-George MR, Murphy KJ, Pickens RC, Iannitti DA, Martinie JB, Baker EH, Vrochides D, Ocuin LM. Pure and Hybrid Deep Learning Models can Predict Pathologic Tumor Response to Neoadjuvant Therapy in Pancreatic Adenocarcinoma: A Pilot Study. Am Surg 2020; 87:1901-1909. [PMID: 33381979 DOI: 10.1177/0003134820982557] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neoadjuvant therapy may improve survival of patients with pancreatic adenocarcinoma; however, determining response to therapy is difficult. Artificial intelligence allows for novel analysis of images. We hypothesized that a deep learning model can predict tumor response to NAC. METHODS Patients with pancreatic cancer receiving neoadjuvant therapy prior to pancreatoduodenectomy were identified between November 2009 and January 2018. The College of American Pathologists Tumor Regression Grades 0-2 were defined as pathologic response (PR) and grade 3 as no response (NR). Axial images from preoperative computed tomography scans were used to create a 5-layer convolutional neural network and LeNet deep learning model to predict PRs. The hybrid model incorporated decrease in carbohydrate antigen 19-9 (CA19-9) of 10%. Accuracy was determined by area under the curve. RESULTS A total of 81 patients were included in the study. Patients were divided between PR (333 images) and NR (443 images). The pure model had an area under the curve (AUC) of .738 (P < .001), whereas the hybrid model had an AUC of .785 (P < .001). CA19-9 decrease alone was a poor predictor of response with an AUC of .564 (P = .096). CONCLUSIONS A deep learning model can predict pathologic tumor response to neoadjuvant therapy for patients with pancreatic adenocarcinoma and the model is improved with the incorporation of decreases in serum CA19-9. Further model development is needed before clinical application.
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Affiliation(s)
- Michael D Watson
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Maria R Baimas-George
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Keith J Murphy
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Ryan C Pickens
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Lee M Ocuin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
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26
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Hue JJ, Katayama E, Sugumar K, Winter JM, Ammori JB, Rothermel LD, Hardacre JM, Ocuin LM. The importance of multimodal therapy in the management of nonmetastatic adenosquamous carcinoma of the pancreas: Analysis of treatment sequence and strategy. Surgery 2020; 169:1102-1109. [PMID: 33376004 DOI: 10.1016/j.surg.2020.11.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/07/2020] [Accepted: 11/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adenosquamous carcinoma of the pancreas has historically poor survival. We analyzed survival outcomes stratified by treatment regimen and sequence using an administrative dataset. METHODS Adult patients with nonmetastatic adenosquamous carcinoma of the pancreas were identified using the National Cancer Database (2010-2016). Multivariable analyses were used to determine factors associated with receipt of neoadjuvant or adjuvant chemotherapy. Overall survival was estimated by Kaplan-Meier analysis and a multivariable Cox model was used to evaluate factors associated with survival. RESULTS A total of 838 patients with adenosquamous carcinoma of the pancreas were included in the analysis. The median age was 69 years and 64.7% of patients underwent pancreatectomy. Among patients who underwent pancreatectomy, 60.5% received adjuvant chemotherapy, 14.8% received neoadjuvant chemotherapy, and 24.7% underwent surgery alone. Older age and increasing comorbidity index were associated with a reduced likelihood of receiving neoadjuvant or adjuvant chemotherapy. Median survival of patients who received chemotherapy alone was similar compared with patients who underwent pancreatectomy alone (9.2 vs 7.2 months, P = .504). Survival was improved if patients received both chemotherapy and pancreatectomy (neoadjuvant = 19.6 months, hazard ratio = 0.58; adjuvant = 19.4 months, hazard ratio = 0.64) compared with pancreatectomy alone. CONCLUSION Patients with adenosquamous carcinoma of the pancreas who do not receive multimodal therapy have poor survival. The sequence of chemotherapy and pancreatectomy is not associated with survival, but 25% of patients who undergo surgery do not receive chemotherapy. Given that there is no difference in median survival between patients who undergo pancreatectomy alone or receive chemotherapy alone, our data question whether neoadjuvant chemotherapy should be considered in patients with potentially resectable adenosquamous carcinoma of the pancreas.
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Affiliation(s)
- Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | | | - Kavin Sugumar
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Lee M Ocuin
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Atrium Health, Charlotte, NC.
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Postoperative pancreatic fistulas decrease the survival of pancreatic cancer patients treated with surgery after neoadjuvant chemoradiotherapy: A retrospective analysis. Surg Oncol 2020; 35:527-532. [PMID: 33160278 DOI: 10.1016/j.suronc.2020.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/13/2020] [Accepted: 10/19/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES A postoperative pancreatic fistula (POPF) is a critical complication after surgery for pancreatic cancer. Whether a POPF affects the long-term prognosis of pancreatic cancer cases remains controversial. This study aimed to clarify the effect of a POPF on the long-term prognosis of pancreatic cancer patients, especially after neoadjuvant chemoradiotherapy (NACRT). METHODS Patients who underwent curative pancreatectomy for pancreatic cancer between January 2012 and June 2019 at Kyoto University Hospital were retrospectively investigated. A fistula ≥ Grade B was considered a POPF. RESULTS During the study period, 148 patients underwent upfront surgery (Upfront group), and 52 patients underwent surgery after NACRT (NACRT group). A POPF developed in 16% of patients in the Upfront group and 13% in the NACRT group (p = 0.824). In the Upfront group, development of a POPF did not have a significant effect on recurrence-free survival (p = 0.766) or overall survival (p = 0.863). However, in the NACRT group, development of a POPF significantly decreased recurrence-free survival (HR 5.856, p = 0.002) and overall survival (HR 7.097, p = 0.020) on multivariate analysis. CONCLUSIONS The development of a POPF decreases the survival of pancreatic cancer patients treated by surgery after NACRT.
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Watson MD, Thompson KJ, Musselwhite LW, Hwang JJ, Baker EH, Martinie JB, Vrochides D, Iannitti DA, Ocuin LM. The treatment sequence may matter in patients undergoing pancreatoduodenectomy for early stage pancreatic cancer in the era of modern chemotherapy. Am J Surg 2020; 222:159-166. [PMID: 33121658 DOI: 10.1016/j.amjsurg.2020.10.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/08/2020] [Accepted: 10/22/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND The aim of this study was to investigate outcomes associated with neoadjuvant chemotherapy in patients undergoing pancreatoduodenectomy for early stage pancreatic adenocarcinoma in the era of modern chemotherapy. METHODS The National Cancer Database (2010-2016) was queried for patients with clinical stage 0-2 pancreatic adenocarcinoma who underwent pancreatoduodenectomy. Patients who underwent up-front pancreatoduodenectomy were propensity matched to patients who received neoadjuvant chemotherapy. Postoperative outcomes, pathologic outcomes, and overall survival were compared. RESULTS A total of 2036 patients were in each group. Neoadjuvant chemotherapy was associated with shorter length of stay, lower 30-day readmission rate, and lower 30 and 90-day mortality rates (all p < 0.05). Neoadjuvant chemotherapy was associated with lower rates of positives nodes and positive resection margins (all p < 0.0001). Neoadjuvant chemotherapy was associated with longer survival (26.8 vs. 22.1months, p < 0.0001). Patients who received neoadjuvant chemotherapy followed by surgery and adjuvant therapy had the longest OS, followed by neoadjuvant + surgery, surgery + adjuvant therapy, and surgery alone (29.8 vs. 25.6 vs. 23.9 vs. 13.1 months; p < 0.0001). CONCLUSIONS Neoadjuvant chemotherapy is associated with improved postoperative outcomes, oncologic outcomes, and overall survival in patients with early stage pancreatic adenocarcinoma. Neoadjuvant chemotherapy should be considered in all patients with early stage pancreatic adenocarcinoma.
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Affiliation(s)
- Michael D Watson
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, USA
| | - Kyle J Thompson
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, USA
| | - Laura W Musselwhite
- Division of Hematology/Oncology, Department of Medicine, Atrium Health, Charlotte, NC, USA
| | - Jimmy J Hwang
- Division of Hematology/Oncology, Department of Medicine, Atrium Health, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, USA
| | - Lee M Ocuin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, USA.
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Borderline Resectable and Locally Advanced Pancreatic Cancer: FDG PET/MRI and CT Tumor Metrics for Assessment of Pathologic Response to Neoadjuvant Therapy and Prediction of Survival. AJR Am J Roentgenol 2020; 217:730-740. [PMID: 33084382 DOI: 10.2214/ajr.20.24567] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND. Imaging biomarkers of response to neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDA) are needed to optimize treatment decisions and long-term outcomes. OBJECTIVE. The purpose of this study was to investigate metrics from PET/MRI and CT to assess pathologic response of PDA to NAT and to predict overall survival (OS). METHODS. This retrospective study included 44 patients with 18F-FDG-avid borderline resectable or locally advanced PDA on pretreatment PET/MRI who also underwent post-NAT PET/MRI before surgery between August 2016 and February 2019. Carbohydrate antigen 19-9 (CA 19-9) level, metabolic metrics from PET/MRI, and morphologic metrics from CT (n = 34) were compared between pathologic responders (College of American Pathologists scores 0 and 1) and nonresponders (scores 2 and 3). AUCs were measured for metrics significantly associated with pathologic response. Relation to OS was evaluated with Cox proportional hazards models. RESULTS. Among 44 patients (22 men, 22 women; mean age, 62 ± 11.6 years), 19 (43%) were responders, and 25 (57%) were nonresponders. Median OS was 24 months (range, 6-42 months). Before treatment, responders and nonresponders did not differ in CA 19-9 level, metabolic metrics, or CT metrics (p > .05). After treatment, responders and nonresponders differed in complete metabolic response (CMR) (responders, 89% [17/19]; nonresponders, 40% [10/25]; p = .04], mean change in SUVmax (ΔSUVmax; responders, -70% ± 13%; nonresponders, -37% ± 42%; p < .001), mean change in SUVmax corrected to serum glucose level (ΔSUVgluc) (responders, -74% ± 12%; nonresponders, -30% ± 58%; p < .001), RECIST response on CT (responders, 93% [13/14]; nonresponders, 50% [10/20]; p = .02)], and mean change in tumor volume on CT (ΔTvol) (responders, -85% ± 21%; nonresponders, 57% ± 400%; p < .001). The AUC of CMR for pathologic response was 0.75; ΔSUVmax, 0.83; ΔSUVgluc, 0.87; RECIST, 0.71; and ΔTvol 0.86. The AUCs of bivariable PET/MRI and CT models were 0.83 (CMR and ΔSUVmax), 0.87 (CMR and ΔSUVgluc), and 0.87 (RECIST and ΔTvol). OS was associated with CMR (p = .03), ΔSUVmax (p = .003), ΔSUVgluc (p = .003), and RECIST (p = .046). CONCLUSION. Unlike CA 19-9 level, changes in metabolic metrics from PET/MRI and morphologic metrics from CT after NAT were associated with pathologic response and OS in patients with PDA, warranting prospective validation. CLINICAL IMPACT. Imaging metrics associated with pathologic response and OS in PDA could help guide clinical management and outcomes for patients with PDA who undergo emergency therapeutic interventions.
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Ocuin LM, Hardacre JM, Ammori JB, Rothermel LD, Mohamed A, Selfridge JE, Bajor D, Winter JM. Neoadjuvant chemotherapy is associated with improved survival in patients with left-sided pancreatic adenocarcinoma. J Surg Oncol 2020; 122:1595-1603. [PMID: 32844445 DOI: 10.1002/jso.26196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy is used infrequently in the management of distal pancreatic cancers. We investigated outcomes associated with neoadjuvant chemotherapy or up-front surgery in patients undergoing distal pancreatectomy. METHODS The National Cancer Database (2004-2016) was queried for patients with pancreas cancer who underwent distal pancreatectomy. Demographics, clinical characteristics, postoperative outcomes, pathologic outcomes, and overall survival were analyzed by univariate and multivariate analysis. RESULTS Six thousand five-hundred and twenty-three patients were included, including 5,643 who underwent up-front distal pancreatectomy and 880 who received neoadjuvant therapy. Factors associated with receipt of neoadjuvant chemotherapy included care at academic/research programs, higher education level, higher clinical T stage, higher clinical N stage, and elevated carbohydrate antigen 19-9 level. Patients who received neoadjuvant therapy had fewer positive lymph nodes, higher margin-negative resection rate, lower 30-day readmission rate, and lower 90-day mortality rate. Patients who received neoadjuvant therapy had longer median overall survival (28.8 vs 22.0 months; P < .001). On multivariate analysis, neoadjuvant therapy remained independently associated with improved survival (hazards ratio, 0.72; 95% confidence inteval, 0.63-0.82; P < .001). CONCLUSIONS Neoadjuvant therapy in patients with left-sided pancreatic cancers is associated with improved pathologic outcomes as well as longer overall survival. Neoadjuvant therapy should be considered in all patients with PDAC regardless of tumor location.
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Affiliation(s)
- Lee M Ocuin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, North Carolina
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - Luke D Rothermel
- Division of Surgical Oncology, Department of Surgery, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - Amr Mohamed
- Division of Hematology/Oncology, Department of Medicine, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - Jennifer E Selfridge
- Division of Hematology/Oncology, Department of Medicine, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - David Bajor
- Division of Hematology/Oncology, Department of Medicine, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
| | - Jordan M Winter
- Division of Surgical Oncology, Department of Surgery, Cleveland Medical Center, University Hospitals, Cleveland, Ohio
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Nishiwada S, Sho M, Banwait JK, Yamamura K, Akahori T, Nakamura K, Baba H, Goel A. A MicroRNA Signature Identifies Pancreatic Ductal Adenocarcinoma Patients at Risk for Lymph Node Metastases. Gastroenterology 2020; 159:562-574. [PMID: 32376411 PMCID: PMC7483849 DOI: 10.1053/j.gastro.2020.04.057] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Pancreatic ductal adenocarcinomas (PDACs) frequently metastasize to the lymph nodes; strategies are needed to identify patients at highest risk for lymph node metastases. We performed genome-wide expression profile analyses of PDAC specimens, collected during surgery or endoscopic ultrasound-guided fine-need aspiration (EUS-FNA), to identify a microRNA (miRNA) signature associated with metastasis to lymph nodes. METHODS For biomarker discovery, we analyzed miRNA expression profiles of primary pancreatic tumors from 3 public data sets (The Cancer Genome Atlas, GSE24279, and GSE32688). We then analyzed 157 PDAC specimens (83 from patients with lymph node metastases and 74 without) from Japan, collected from 2001 through 2017, for the training cohort and 107 PDAC specimens (63 from patients with lymph node metastases and 44 without) from a different medical center in Japan, from 2002 through 2016, for the validation cohort. We also analyzed samples collected by EUS-FNA before surgery from 47 patients (22 patients with lymph node metastases and 25 without; 17 for the training cohort and 30 from the validation cohort) and 62 specimens before any treatment from patients who received neoadjuvant chemotherapy (9 patients with lymph node metastasis and 53 without) for additional validation. Multivariate logistic regression analyses were used to evaluate the statistical differences in miRNA expression between patients with vs without metastases. RESULTS We identified an miRNA expression pattern associated with diagnosis of PDAC metastasis to lymph nodes. Using logistic regression analysis, we optimized and trained a 6-miRNA risk prediction model for the training cohort; this model discriminated patients with vs without lymph node metastases with an area under the curve (AUC) of 0.84 (95% confidence interval [CI], 0.77-0.89). In the validation cohort, the model identified patients with vs without lymph node metastases with an AUC of 0.73 (95% CI, 0.64-0.81). In EUS-FNA biopsy samples, the model identified patients with vs without lymph node metastases with an AUC of 0.78 (95% CI, 0.63-0.89). The miRNA expression pattern was an independent predictor of PDAC metastasis to lymph nodes in the validation cohort (odds ratio, 17.05; 95% CI, 2.43-119.57) and in the EUS-FNA cohort (95% CI, 0.65-0.87). CONCLUSIONS Using data and tumor samples from 3 independent cohorts, we identified an miRNA signature that identifies patients at risk for PDAC metastasis to lymph nodes. The signature has similar levels of accuracy in the analysis of resected tumor specimens and EUS-FNA biopsy specimens. This model might be used to select treatment and management strategies for patients with PDAC.
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Affiliation(s)
- Satoshi Nishiwada
- Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, TX, USA,Department of Surgery, Nara Medical University, Nara, Japan,Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Jasjit K Banwait
- Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, TX, USA
| | - Kensuke Yamamura
- Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, TX, USA,Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | | | - Kota Nakamura
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Ajay Goel
- Center for Gastrointestinal Research, Baylor Scott & White Research Institute and Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, Texas; Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope Comprehensive Cancer Center, Duarte, California.
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32
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Małczak P, Sierżęga M, Stefura T, Kacprzyk A, Droś J, Skomarovska O, Krzysztofik M, Major P, Pędziwiatr M. Arterial resections in pancreatic cancer - Systematic review and meta-analysis. HPB (Oxford) 2020; 22:961-968. [PMID: 32360186 DOI: 10.1016/j.hpb.2020.04.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/20/2020] [Accepted: 04/09/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The number of pancreatic resections due to cancers is increasing. While concomitant venous resections are routinely performed in specialized centers, arterial resections are still controversial. Nevertheless they are performed in patients presenting with locally advanced tumors. Our aim was to summarize currently available literature comparing peri-operative and long-term outcomes of arterial and non-arterial pancreatic resections. METHODS We included studies comparing pancreatic operations with and without concomitant arterial resection. Inclusion criteria were morbidity or mortality. Studies additionally reporting venous resections with no possibility of excluding this data during the extraction were discarded. RESULTS The initial search yielded 1651 records. Finally, 19 studies were included in the analysis involving 2710 patients. Arterial resection was associated with a greater risk of death(RR: 4.09; p < 0.001) and complications (RR: 1.4; p = 0.01). There were no differences in the rate of pancreatic fistula, biliary fistula rate, cardiopulmonary complications, length of hospital stay and non-R0 rate. Oncologically, patients after arterial resection were at higher risk of worse 3-year survival. CONCLUSION Arterial resection in pancreatic cancer is associated with an increased risk of mortality and complications in comparison to standard non-arterial resections. Nevertheless, arterial resection may become a viable treatment for selected patients in high volume centers.
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Affiliation(s)
- Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Marek Sierżęga
- 1st Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Tomasz Stefura
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Artur Kacprzyk
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Droś
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Oksana Skomarovska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Marta Krzysztofik
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
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Cloyd JM, Heh V, Pawlik TM, Ejaz A, Dillhoff M, Tsung A, Williams T, Abushahin L, Bridges JFP, Santry H. Neoadjuvant Therapy for Resectable and Borderline Resectable Pancreatic Cancer: A Meta-Analysis of Randomized Controlled Trials. J Clin Med 2020; 9:jcm9041129. [PMID: 32326559 PMCID: PMC7231310 DOI: 10.3390/jcm9041129] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/07/2020] [Accepted: 04/13/2020] [Indexed: 12/15/2022] Open
Abstract
The efficacy of neoadjuvant therapy (NT) versus surgery first (SF) for pancreatic ductal adenocarcinoma (PDAC) remains controversial. A random-effects meta-analysis of only prospective randomized controlled trials (RCTs) comparing NT versus SF for potentially resectable (PR) or borderline resectable (BR) PDAC was performed. Among six RCTs including 850 patients, 411 (48.3%) received NT and 439 (51.6%) SF. In all included trials, NT was gemcitabine-based: four using chemoradiation and two chemotherapy alone. Based on an intention-to-treat analysis, NT resulted in improved overall survival (OS) compared to SF (HR 0.73, 95% CI 0.61–0.86). This effect was independent of anatomic classification (PR: hazard ratio (HR) 0.73, 95% CI 0.59–0.91; BR: HR 0.51 95% CI 0.28–0.93) or NT type (chemoradiation: HR 0.77, 95% CI 0.61–0.98; chemotherapy alone: HR 0.68, 95% CI 0.54–0.87). Overall resection rate was similar (risk ratio (RR) 0.93, 95% CI 0.82–1.04, I2 = 39.0%) but NT increased the likelihood of a margin-negative (R0) resection (RR 1.51, 95% CI 1.18–1.93, I2 = 0%) and having negative lymph nodes (RR 2.07, 95% CI 1.47–2.91, I2 = 12.3%). In this meta-analysis of prospective RCTs, NT significantly improved OS in an intention-to-treat fashion, compared with SF for localized PDAC. Randomized controlled trials using contemporary multi-agent chemotherapy will be needed to confirm these findings and to define the optimal NT regimen.
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Affiliation(s)
- Jordan M. Cloyd
- Division of Surgical Oncology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
- Correspondence: ; Tel.: +614-293-4583; Fax: +614-366-0003
| | - Victor Heh
- Division of Surgical Oncology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Timothy M. Pawlik
- Division of Surgical Oncology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Allan Tsung
- Division of Surgical Oncology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Terence Williams
- Radiation Oncology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Laith Abushahin
- Internal Medicine, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - John F. P. Bridges
- Biomedical Informatics, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Heena Santry
- Division of Surgical Oncology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
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Cloyd JM, Tsung A, Hays J, Wills CE, Bridges JFP. Neoadjuvant therapy for resectable pancreatic ductal adenocarcinoma: The need for patient-centered research. World J Gastroenterol 2020; 26:375-382. [PMID: 32063686 PMCID: PMC7002907 DOI: 10.3748/wjg.v26.i4.375] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/02/2020] [Accepted: 01/11/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma is an aggressive cancer with high recurrence rates following surgical resection. While adjuvant chemotherapy improves survival, a significant proportion of patients are unable to initiate or complete all intended therapy following pancreatectomy due to postoperative complications or poor performance status. The administration of chemotherapy prior to surgical resection is an alternative strategy that ensures its early and near universal delivery as well as improves margin-negative resection rates and potentially improves long-term survival outcomes. Neoadjuvant therapy is increasingly being recommended to patients with pancreatic ductal adenocarcinoma, however, patient-centered research on its use is lacking. In this review, we highlight opportunities to focus research efforts in the domains of patient preferences, patient-reported outcomes, patient experience, and survivorship. Novel research in these areas may identify relevant barriers and facilitators to the use of neoadjuvant therapy thereby increasing its utilization, improve shared-decision making for patients and providers, and optimize the experience of those undergoing neoadjuvant therapy.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - John Hays
- Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, United States
| | - Celia E Wills
- College of Nursing, The Ohio State University, Columbus, OH 43210, United States
| | - John FP Bridges
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH 43210, United States
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