Preoperative chemotherapy of chemoradiotherapy for the treatment of adenocarcinoma of the pancreas and ampulla of Vater

Complete Response after Chemoradiation in Ampullary Carcinoma: A Case Report

Aims and Background

The case of a 70-year-old patient with resectable, poorly differentiated adenocarcinoma of the ampulla of Vater is presented.

Patient and Methods

Due to intraoperative hemorrhagic complications, surgical resection was not feasible. The patient was treated with radiochemotherapy consisting of external beam radiotherapy (50.4 Gy; 1.8 Gy/fraction; 5 fractions/week) plus 5-FU (1000 mg/m2/day, continuous IV infusion, days 2–5, week 1 and 5 of radiotherapy) and mitomycin C (10 mg/m2 IV, day 2, week 1 of radiotherapy).

Results

At five years’ follow-up the patient was in good general condition, without any signs of disease according to CT scan, endoscopic retrograde cholangiopancreatography and tumor marker determination. Multiple random biopsies performed in the ampullary region were negative for tumor growth.

Conclusions

In patients with ampullary carcinoma the use of concurrent chemoradiation should be considered, particularly when surgical resection is unfeasible due to medical contraindications or locally advanced disease.

Pathologic Response to Preoperative Therapy as a Novel Prognosticator for Ampullary and Duodenal Adenocarcinoma

BACKGROUND

The prognostic impact of pathologic response to preoperative therapy on patients with duodenal adenocarcinoma (DA) and ampullary adenocarcinoma (AMPA) has not been established.

METHODS

A retrospective review of 266 patients who underwent curative resection for DA (n = 97) or AMPA (n = 169) during 1993-2015 was performed. For patients who underwent preoperative therapy, the pathologic response was systematically evaluated and classified as major (0-49% of viable residual tumor cells) or minor (≥ 50% of viable residual tumor cells). Uni- and multivariable analyses were performed to identify predictors of pathologic response and disease-specific survival (DSS).

RESULTS

For the 79 patients treated with preoperative therapy (DA: n = 34; AMPA: n = 45), concomitant use of radiation (80%, 67/79) was the sole independent predictor of major pathologic response (odds ratio [OR] 8.17; 95% confidence interval [CI] 1.85-58.2; P = 0.005). The patients with major pathologic response had a better 5-year DSS rate than the patients with minor pathologic response (DA: 65 vs 25%; P = 0.028; AMPA: 85 vs 43%; P = 0.016). In the multivariable analysis of DSS for the 79 patients who underwent preoperative therapy, major pathologic response was the sole predictor of improved DSS (hazard ratio [HR] 2.88; 95% CI 1.41-5.98; P = 0.004). In the multivariable analysis of DSS for the entire cohort, pathologic stage 2 or lower was the sole predictor of better DSS.

CONCLUSION

The major pathologic response to preoperative therapy predicted improved DSS after resection of DA and AMPA and might represent a new prognosticator after resection of DA and AMPA.

Pathological Complete Remission of Pancreatic Cancer Following Neoadjuvant Chemoradiation Therapy; Not the End of Battles

In spite of controversial issues, pancreatectomy following neoadjuvant chemoradiation therapy (NeoCRT) has been applied in treating advanced pancreatic cancer. Cases of pathological complete remission (pCR) following NeoCRT is rare, and its long-term follow-up data are still lacking.From January 2000 to December 2012, medical records of the patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma were retrospectively reviewed. Characteristics of the patients with pCR were summarized and their long-term follow-up data were analyzed.Among 86 patients with pancreatic cancer who underwent radical pancreatectomy following NeoCRT, 10 patients (11.6%) were reported to pCR. Nine out of 10 patients received gemcitabine-based chemoradiation therapy. Median pre-NeoCRT serum CA 19-9 was 313.5 U/ml, and post-NeoCRT serum CA 19-9 was 9.9 U/ml, which was shown to be significant difference between 2 serum CA 19-9 level (P = 0.005). Pylorus-preserving pancreaticoduodenectomy was done in 8 patients, and the others received distal pancreatosplenectomy. Postoperative chemotherapy was received in 6 patients. Disease-free survival was statistically superior in patients with pCR than patients without pCR (P < 0.05). However, 5 patients experienced cancer recurrence and no clinicopathologic variables including preoperative resectability could not predict the potential recurrence of tumor in patients with pCR (P > 0.05).pCR is rarely reported following NeoCRT, but this condition is not telling the cure of the disease. Early recurrence in the pattern of liver metastasis and peritoneal seeding can be expected. However, long-term survival could be maintained in patients without recurrence. Further investigation is necessary for predicting failure of treatment.

Controversial issues of neoadjuvant treatment in borderline resectable pancreatic cancer

Pancreatic ductal adenocarcinoma is known as one of the most fatal malignant diseases in gastrointestinal system. Approximately 20% of patients are deemed resectable at the time of diagnosis. Preoperative neoadjuvant therapy to the borderline resectable pancreatic cancer (BRPC) has been challenged to achieve down-staging of cancer, to avoid unnecessary major operation if the pancreatic cancer progresses and distant metastasis develops during preoperative treatment, and to avoid delayed adjuvant treatment after major operation due to postoperative complications and poor general condition after major surgery. However, there are some controversial issues influencing the clinical interpretation of surgical and oncologic outcomes of pancreatectomy following neoadjuvant treatment in managing BRPC. This manuscript reviews the current controversial issues in managing BRPC in order to enhance proper understanding the current status and potential role of neoadjuvant treatment in managing BRPC.

Complete pathological response following down-staging chemoradiation in locally advanced pancreatic cancer: Challenging the boundaries

Pancreatic cancer is an aggressive malignancy, relatively resistant to chemotherapy and radiotherapy, which usually presents late. Disease specific mortality approaches unity despite advances in adjuvant therapy. We present the first reported case of complete pathological response following neoadjuvant therapy in a locally advanced pancreatic adenocarcinoma.

Dosimetric Feasibility of Hypofractionated Proton Radiotherapy for Neoadjuvant Pancreatic Cancer Treatment

PURPOSE

To evaluate tumor and normal tissue dosimetry of a 5 cobalt gray equivalent (CGE) x 5 fraction proton radiotherapy schedule, before initiating a clinical trial of neoadjuvant, short-course proton radiotherapy for pancreatic adenocarcinoma.

METHODS AND MATERIALS

The first 9 pancreatic cancer patients treated with neoadjuvant intensity-modulated radiotherapy (1.8 Gy x 28) at the Massachusetts General Hospital had treatment plans generated using a 5 CGE x 5 fraction proton regimen. To facilitate dosimetric comparisons, clinical target volumes and normal tissue volumes were held constant. Plans were optimized for target volume coverage and normal tissue sparing.

RESULTS

Hypofractionated proton and conventionally fractionated intensity-modulated radiotherapy plans both provided acceptable target volume coverage and dose homogeneity. Improved dose conformality provided by the hypofractionated proton regimen resulted in significant sparing of kidneys, liver, and small bowel, evidenced by significant reductions in the mean doses, expressed as percentage prescribed dose, to these structures. Kidney and liver sparing was most evident in low-dose regions (< or =20% prescribed dose for both kidneys and < or =60% prescribed dose for liver). Improvements in small-bowel dosimetry were observed in high- and low-dose regions. Mean stomach and duodenum doses, expressed as percentage prescribed dose, were similar for the two techniques.

CONCLUSIONS

A proton radiotherapy schedule consisting of 5 fractions of 5 CGE as part of neoadjuvant therapy for adenocarcinoma of the pancreas seems dosimetrically feasible, providing excellent target volume coverage, dose homogeneity, and normal tissue sparing. Hypofractionated proton radiotherapy in this setting merits Phase I clinical trial investigation.

[The role of neoadjuvant chemoradiation in pancreatic cancer]

Although complete surgical resection, when possible, leads to prolonged survival in pancreatic cancer, if used alone, its results remain sub-optimal. Neoadjuvant strategies are recent in pancreatic cancer: in primary resectable tumors, they ensure that all patients obtain additional treatment to complete surgery; in locally advanced tumors, they allow a better selection of candidates for curative resection. By delaying surgery, neoadjuvant strategies modify the initial diagnostic process and the symptomatic treatment of pancreatic cancer. Several recent phase I-II studies have confirmed the feasibility and efficacy of the association of chemotherapy and radiotherapy, which is well-tolerated and is associated with better local control and survival. Due to the aggressiveness of pancreatic cancers, most recent cytotoxic agents should be associated with modern radiation techniques. Neoadjuvant chemoradiation is under evaluation in pancreatic cancers, and no randomized phase III trials comparing neoadjuvant and adjuvant therapeutic sequences has been reported. Moreover, radiological and pathological evaluations, not only at diagnosis, but also after preoperative chemoradiation, must be standardized to improve the selection of patients who will benefit from this multi-modal treatment.

Patterns and predictors of failure after curative resections of carcinoma of the ampulla of Vater

BACKGROUND

Curative resection does not always equate with long-term survival. The aim was to identify patterns and predictors of failure and independent factors of prognosis after curative resection.

METHODS

Sixty-six patients with ampullary carcinoma who underwent surgical intervention were reviewed. Fifty-nine patients underwent pancreaticoduodenectomy. Cox regression analysis, log-rank test, Fisher exact test, or chi(2) test was used.

RESULTS

No patient died as a result of surgery; major complications occurred in three, and the 5-year survival rate after curative resection (n = 55) was 52.6%. Significant survival predictors were preoperative serum carcinoembryonic antigen level; gross tumor appearance; tumor, node, and tumor node metastasis stage; and microscopic lymphatic vessel and venous invasion in the primary tumor. Multivariate analysis demonstrated that lymphatic vessel invasion, tumor, and tumor node metastasis stage were significant independent prognostic factors. No patient experienced locoregional failure alone; all 24 relapsed patients had distant failure, and six of them had both. The liver was the most frequent metastatic organ, followed by nodes, peritoneum, lung, and bone. The carcinoembryonic antigen and carbohydrate antigen levels and lymphatic vessel and venous invasion were significant predictors of distant failure, and the mean time to relapse was 13 (range, 0.7-33) months.

CONCLUSIONS

Curative resection is associated with significant survival; however, effective systemic adjuvant therapy is needed to prevent distant failure for patients with elevated carcinoembryonic antigen and carbohydrate antigen levels or positive lymphatic vessel or venous invasion. A 3-year follow-up period would be necessary to document relapses.

A novel cell line and xenograft model of ampulla of Vater adenocarcinoma

Ampulla of Vater cancers (AVC) are of clinical relevance, as they represent more than one-third of patients undergoing surgery for pancreaticoduodenal malignancies and have a better prognosis than periampullary cancers of pancreaticobiliary origin. The availability of cellular models is crucial to perform cell biology and pharmacological studies and clarify the relationship between AVC and pancreatic and biliary cancers. Numerous cell lines are available for pancreatic and biliary adenocarcinomas, while only two have been reported recently for AVC. These were derived from a poor and a well-differentiated AVC, and both had wild-type K- ras and mutated p53. We report the establishment of a novel AVC cell line (AVC1) derived from a moderately differentiated cancer, having a mutated K- ras, wild-type p53, and methylated p16. Thus, our cell line adds to the spectrum of available in vitro models representative of the different morphological and molecular presentations of primary AVC. We further characterized AVC1 for the expression of relevant cell surface molecules and sensitivity to chemotherapeutic agents of common clinical use. It expresses MHC-I and CD95/Fas, while HLA-DR, CD40, CD80, CD86, MUC-1, MUC-2, and ICAM-1/CD54 are absent. It has a low to moderate sensitivity to both 5-FU and gemcitabine, at variance with much higher sensitivity displayed by two pancreatic ductal carcinoma cell lines. Lastly, AVC1 can be readily xenografted in immunodeficient mice, making it a suitable model for pre-clinical studies.

Review article: chemotherapy for pancreatic cancer

Pancreatic cancer is a common, highly lethal disease that is rising in incidence. Chemotherapy based on 5-fluorouracil (5-FU) has been shown to prolong survival in advanced pancreatic cancer. Gemcitabine improves major symptoms and survival outcomes compared with bolus 5-FU. Many novel small molecules are being widely and actively researched. These compounds are based on classical mechanisms of action as well as biological therapies targeting novel cellular survival pathways, and include fluoropyrimidines, nucleoside cytidine analogues, platinum analogues, topoisomerase-inhibitors, antimicrotubule agents, proteasome inhibitors, vitamin D analogues, arachidonic acid pathway inhibitors, histone deacytylator inhibitors, farnesyltransferase inhibitors and epidermal growth factor receptor therapies. Adjuvant chemotherapy has also demonstrated the best survival outcomes following resection compared to other adjuvant or neo-adjuvant strategies such as radiation-based treatments. These benefits are superimposed on the dramatic increase in resectability rates and reduction in post-operative mortality achieved by centralisation of treatment in high-volume speciality centres. Newer 'small-molecule' drugs as well as the latest 'large-molecule' biological agents hold considerable promise for the future. Real advances are anticipated over the next five years but are dependent on large randomised controlled trials for success.

Pancreatic Carcinoma Deemed Unresectable at Exploration May be Resected for Cure: An Institutional Experience

Only a minority of patients with a diagnosis of pancreatic adenocarcinoma (PA) have disease amenable to curative resection. Between April 1987 and March 1999, 40 patients with pancreatic adenocarcinoma deemed unresectable at exploration at other institutions were considered for neoadjuvant treatments and then re-evaluated for possible re-exploration. We retrospectively compared the clinical outcomes, including overall survival (OS), among three groups: Group A, 22 previously unresectable patients who were subsequently successfully resected, 20 after induction therapy; Group B, 31 patients who received preoperative chemoradiotherapy before their only operation; and Group C, 33 patients who were primarily resected, 27 of whom were then treated with adjuvant therapy. Of those resectable from Group A, 5 required portal venorraphy and 3 had hepatic artery reconstruction. Eighteen of the 40 patients were unresectable because of progression of disease with a mean OS of 8 months; 12 were assessed at second laparotomy; 6 were excluded from second operation on the basis of preoperative imaging studies. Kaplan-Meier curves showed no differences in OS among the three groups: OS in Group A was 34 months; Group B, 21; and Group C, 13 ( P = 0.15). Margin status was comparable in all three groups ( P = 0.52). As expected, nodal positivity was greatest in Group C ( P = 0.001). There were no operative mortalities in Group A, and the morbidity rate was comparable with that of Groups B and C. Upon re-evaluation, many tumors (54%) previously deemed “unresectable” were surgically extirpated for cure with a median survival comparable with that of patients who did not undergo previous exploration.