Role of chemoradiotherapy in the adjuvant and neoadjuvant settings for resectable pancreatic cancer

Perioperative risk factors for overall survival of patients with pancreatic ductal adenocarcinoma underwent laparoscopic pancreaticoduodenectomy

The postoperative overall survival of patients with pancreatic ductal adenocarcinoma is not optimal. The aim of this study was to explore the perioperative risk factors for overall survival after laparoscopic pancreaticoduodenectomy (LPD) in patients with pancreatic ductal adenocarcinoma (PDAC). From January 2015 to January 2022, consecutive patients who underwent LPD with a pathological diagnosis of PDAC at our center were included in the study. LASSO regression and multivariate Cox regression were used to explore perioperative risk factors associated with overall survival. A total of 159 patients were included in the study. The median overall survival was 21 months. In the multivariate analysis, the level of direct bilirubin in serum (HR: 1.01, 95% CI 1.00-1.02, P = 0.043), postoperative pancreatic fistula (HR: 0.36, 95% CI 0.18-0.86, P = 0.010), and adjuvant therapy after surgery within 12 weeks (HR: 0.53, 95% CI 0.34-0.83, P = 0.001) were identified as independent risk factors associated with overall survival. A high level of direct bilirubin in the serum, happened with postoperative pancreatic fistula and delayed postoperative adjuvant therapy are prognostic risk factors affecting the overall survival of patients with PDAC after LPD.

Diagnostic performance for declined microRNA-133a in pancreatic cancer

MicroRNA-133a (MiR-133a) is proven to exhibit a decreasing tendency in several cancers, as well as pancreatic cancer. Through the present study, we inspected performance for serum miR-133a in diagnosing pancreatic cancer. Serum samples were collected from 110 pancreatic cancer and 64 healthy persons. Relative messenger RNA level for miR-133a in serum specimens was gauged adopting quantitative real-time polymerase chain reaction (qRT-PCR), and compared betwixt two groups employing the Student t test. Receiver operating characteristics (ROC) analysis evaluated miR-133a performance in diagnosing pancreatic cancer. MiR-133a displayed a declining trend among pancreatic cancer samples, compared to the healthy controls (P < .001). The reduced miR-133a degree held strong relation to tumor dimension (P = .002), vessel invasion (P = .004), tumor lymph node metastasis stage (P = .002), and lymph node metastasis (P < .001). In addition, ROC analysis demonstrated that the area under the curve value was 0.893, accompanied by a sensitivity of 90.6% and a specificity of 87.2%, revealing fine execution for serum miR-133a in diagnosing cancer. The downregulation of miR-133a might possess a tight relation to hostile advancement in pancreatic cancer. Serum miR-133a could function as a potential diagnostic indicator for pancreatic cancer.

Results of the NRG Oncology/RTOG 0848 Adjuvant Chemotherapy Question-Erlotinib+Gemcitabine for Resected Cancer of the Pancreatic Head: A Phase II Randomized Clinical Trial

PURPOSE

NRG/RTOG 0848 was designed to determine whether adjuvant radiation with fluoropyrimidine sensitization improved survival following gemcitabine-based adjuvant chemotherapy for patients with resected pancreatic head adenocarcinoma. In step 1 of this protocol, patients were randomized to adjuvant gemcitabine versus the combination of gemcitabine and erlotinib. This manuscript reports the final analysis of these step 1 data.

METHODS

Eligibility-within 10 weeks of curative intent pancreaticoduodenectomy with postoperative CA19-9<180. Gemcitabine arm-6 cycles of gemcitabine. Gemcitabine+erlotinib arm-gemcitabine and erlotinib 100 mg/d. Two hundred deaths provided 90% power (1-sided α=0.15) to detect the hypothesized OS signal (hazard ratio=0.72) in favor of the arm 2.

RESULTS

From November 17, 2009 to February 28, 2014, 163 patients were randomized and evaluable for arm 1 and 159 for arm 2. Median age was 63 (39 to 86) years. CA19-9 ≤90 in 93%. Arm 1: 32 patients (20%) grade 4 and 2 (1%) grade 5 adverse events; arm 2, 27 (17%) grade 4 and 3 (2%) grade 5. GI adverse events, arm 1: 22% grade ≥3 and arm 2: 28%, (P=0.22). The median follow-up (surviving patients) was 42.5 months (min-max: <1 to 75). With 203 deaths, the median and 3-year OS (95% confidence interval) are 29.9 months (21.7, 33.4) and 39% (30, 45) for arm 1 and 28.1 months (20.7, 30.9) and 39% (31, 47) for arm 2 (log-rank P=0.62). Hazard ratio (95% confidence interval) comparing OS of arm 2 to arm 1 is 1.04 (0.79, 1.38).

CONCLUSIONS

The addition of adjuvant erlotinib to gemcitabine did not provide a signal for increased OS in this trial.

A single institution experience of the treatment of pancreatic ductal carcinoma: The demand and the role of radiation therapy

We aimed to demonstrate a single institution experience of treatment of pancreatic ductal carcinoma and to identify the role of radiation therapy. We assessed all patients who were diagnosed with pancreatic ductal carcinoma from January 2011 to December 2017. A total of 342 patients were enrolled. Thirteen, 131, 36, and 162 patients had stage I, II, III, and IV disease, respectively (UICC TNM, 7th edition). Among the patients with stages I-III disease, 94 underwent surgery, and the median overall survival (OS) was 33 months. Of patients with stages I-III disease who were not suitable for surgery, 58 patients received chemotherapy, and the median OS was 12 months. Among them, 17 patients received chemoradiotherapy added on chemotherapy and their OS was significantly better than that of patients who received chemotherapy alone. Of patients with stage IV disease, 111 received chemotherapy, and the median OS was 6 months. This study evaluated the demand, role, and outcome of each treatment modality and demonstrated a single institution experience of treatment of pancreatic ductal carcinoma. The demand and role of radiation therapy remained small; however, radiation therapy might have some importance as a local treatment.

The Role of 18F-FDG PET/CT and PET/MRI in Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) remains a difficult disease to treat and continues to portend a poor prognosis, as most patients are unresectable at diagnosis. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) combined with CT (PET/CT) has been a cornerstone in oncological imaging of different cancers; however, the role of PET/CT in PDAC is continually evolving and currently not well established. Studies have shown the potential of PET/CT in guiding the management of patients with PDAC, with possible added benefit over anatomic imaging with CT or MRI in certain scenarios. PET/CT may be useful in diagnosis, initial staging, treatment response assessment, differentiation of recurrent tumor from post-treatment fibrosis, and radiotherapy planning. Additionally, PET/CT may be a cost-effective modality due to upstaging of patients originally deemed as surgical candidates. Recently, the advent of simultaneous PET/MRI represents an exciting advancement in hybrid functional imaging with potential applications in the imaging of PDAC. The advantages of PET/MRI include simultaneous acquisition to improve registration of fusion images, lower radiation dose, superior soft tissue contrast, and availability of multiparametric imaging. Studies are underway to evaluate the utility of PET/MRI in PDAC, including in initial staging and treatment response assessment and to determine the subgroup of patients that will benefit from PET/MRI. Further studies are warranted in both PET/CR and PET/MRI to better understand the role of these modalities in PDAC.

Long-term analysis of 2 prospective studies that incorporate mitomycin C into an adjuvant chemoradiation regimen for pancreatic and periampullary cancers

PURPOSE

The purpose of this study was to report toxicity and long-term survival outcomes of 2 prospective trials evaluating mitomycin C (MMC) with 5-fluorouracil-based adjuvant chemoradiation in resected periampullary adenocarcinoma.

METHODS AND MATERIALS

From 1996 to 2002, 119 patients received an adjuvant 4-drug chemotherapy regimen of 5-fluorouracil, leucovorin, MMC, and dipyridamole with chemoradiation on 2 consecutive trials (trials A and B). Trial A patients received upfront chemoradiation (50 Gy split-course, 2.5 Gy/fraction) followed by 4 cycles of the 4-drug chemotherapy with bolus 5-fluorouracil. Trial B patients received 1 cycle of the 4-drug chemotherapy with continuous infusion 5-fluorouracil followed by continuous chemoradiation (45-54 Gy, 1.8 Gy/fraction) and 2 additional cycles of chemotherapy. Cox proportional hazards models were performed to identify prognostic factors for overall survival (OS).

RESULTS

Of the 62 trial A patients, 61% had pancreatic and 39% nonpancreatic periampullary carcinomas. Trial B (n = 57) consisted of 68% pancreatic and 32% nonpancreatic periampullary carcinomas. Resection margin and lymph node status were similar for both trials. Median follow-up was longer for trial A than trial B (197.5 vs 107.0 months), with median OS of 32.2 and 24.2 months, respectively. Rates of 3-, 5-, and 10-year OS were 48%, 31%, and 26% in trial A and 32%, 23%, and 9% in trial B. On multivariate analysis, lymph node-positive resection was the strongest prognostic factor for OS. A pancreatic primary and positive margin status were also associated with inferior survival (P < .05). Rates of grade ≥3 treatment-related toxicity in trials A and B were 2% and 7%, respectively.

CONCLUSIONS

This is the first study to report long-term outcomes of MMC with 5-fluorouracil-based adjuvant chemoradiation in periampullary cancers. Because MMC may be considered in DNA repair-deficient carcinomas, randomized trials are needed to determine the true benefit of adjuvant MMC.

Survival of patients with pancreatic cancer treated with varied modalities: A single-centre study

The present retrospective chart review examined the overall survival (OS) of patients with pancreatic ductal adenocarcinoma based on the disease stage in a sample of 296 patients with pancreatic cancer. Secondary outcome measurements included OS in chemotherapy vs. supportive treatment groups among metastatic patients, OS based on response to chemotherapy among metastatic patients, and OS and disease free survival (DFS) in surgically resected disease with vs. without adjuvant therapy. Data were analyzed using Kaplan-Meier and multivariate cox-regression analyses based on a 95% confidence interval (CI) or an α-value of 0.05. OS was significantly different based on the disease stage, with 3.63 (95% CI, 2.84-4.43), 6.57 (95% CI, 4.06-9.08) and 15.57 (95% CI, 11.79-19.35) months in the advanced, locally advanced, and localized disease groups, respectively. OS was higher in metastatic-stage patients who received chemotherapy [6.07 months (95% CI, 4.75-7.39)] compared with those who received supportive therapy alone [2.50 months (95% CI, 2.16-2.84; P<.001)]. Metastatic-stage patients with partial or stable response to chemotherapy had higher OS [10.53 months (95% CI, 6.35-14.72)] in comparison with those with progression [6.33 months (95% CI, 5.79-6.88)] or an undocumented response [3.30 months (95% CI, 1.76-4.84; P<0.001)]. In patients who underwent surgical resection of localized disease, adjuvant therapy increased the adjusted OS and DFS as compared with surgical excision alone (P=0.013; 95% CI, 0.278-0.862). Positive margins reduced OS [hazard ratio (HR) 2.670; 95% CI, 1.467-4.860]. The present single-site study has demonstrated that OS may markedly differ on the basis of the disease status at the time of diagnosis. Metastatic-stage patients with stable or partial response to chemotherapy had an increased OS, as did surgical patients with localized disease who received adjuvant treatment, after adjusting for margin status.

Estimation of the Survival Benefit Obtainable From Screening for the Early Detection of Pancreatic Cancer

OBJECTIVE

The chance to improve survival from pancreatic adenocarcinoma relies on early diagnosis through screening, but any screening program is subject to lead-time bias and no data are available in this regard. Aim of the present study was to evaluate the benefit obtainable from a screening program for early detection of pancreatic adenocarcinoma, considering screen-related biases.

METHODS

Monte Carlo simulation was performed using data from 1000 pancreatic cancer patients admitted in a tertiary referral hospital and from pertinent literature. Lead-time bias was assessed and subtracted from expected survival.

RESULTS

Mean expected life expectancy was 13.0 months. Assuming a 20%, 30%, or 50% stage III/IV reduction with screening, pancreatic resections would increase from 217 to 290 in front of a 20% stage III/IV reduction to 324 in front of a 30% reduction and to 385 in front of a 50% reduction. After lead-time adjustment, life expectancies were 14.0, 14.6, and 15.9 months, respectively. The number-needed-to-screen calculation suggests that screening can be harmful in a proportion of patients inversely dependent on the length of follow-up and a significant improvement of survival after diagnosis.

CONCLUSIONS

Pancreatic adenocarcinoma screening program would probably be successful in the presence of a considerable improvement of postdiagnostic survival; otherwise, it only increases surgical procedure amount.

Advances in Molecular Pathology and Treatment of Periampullary Cancers

OBJECTIVES

Periampullary cancers (PACs) include the following 4 traditional anatomic subtypes: pancreatic, ampullary, biliary, or duodenal cancers. This review was performed to highlight recent advances in the genomic and molecular understanding of each PAC subtype and the advances in chemotherapeutic and molecular trials in these cancer subtypes.

RESULTS

Recent advances have highlighted differences in the genomic and molecular features within each PAC subtype. Ampullary cancers can now be further defined accurately into their intestinal and pancreatobiliary subtypes using histomolecular profiling. K-ras mutation, which occurs in most pancreatic cancers, is found to occur less frequently in ampullary (42%-52%), biliary (22%-23%), and duodenal cancers (32%-35%), suggesting crucial differences in targetable mutations in these cancer subtypes.Ampullary cancers of intestinal subtype and duodenal cancers seem to share similarities with colorectal cancer, given that they respond to similar chemotherapeutic regimens. This has potential implications for clinical trials and treatment selection, where PACs are often considered together.

CONCLUSIONS

Future trials should be designed in view of our increased understanding of the different anatomic and histomolecularly profiled subtypes of PAC cancers, which respects their individual molecular characteristics, phenotype, and response to treatment.

Trends in Receipt and Timing of Multimodality Therapy in Early-Stage Pancreatic Cancer

INTRODUCTION

Pancreatic cancer is considered a systemic disease at presentation. Therefore, multimodality therapy with surgical resection and chemotherapy is the standard of care for locoregional disease. We described treatment patterns and time trends with regard to age and treatment center in the receipt of multimodality therapy.

METHODS

We used the National Cancer Data Base to identify patients ≥18 years old with stage I and II pancreatic adenocarcinoma. Treatment was defined as no treatment, resection only, chemotherapy only, or multimodality therapy, which consisted of both chemotherapy (neoadjuvant or adjuvant) and resection. Trends in the receipt and type of treatment were compared.

RESULTS

Of 39,441 patients, 22.8% of patients received no treatment, 18.5% received chemotherapy only, 23.0% underwent surgical resection alone, and 35.8% of patients received multimodality therapy. Receipt of multimodality therapy increased from 31.3% in 2004 to 37.9% in 2011 (p < 0.0001). Patients >55 years were less likely to receive multimodality therapy (56-64 years: OR 0.83, 95% CI 0.78-0.89; 65-75: OR 0.60, 95% CI 0.55-0.65; ≥76: OR 0.17, 95% CI 0.16-0.19 compared to patients 18-55). Compared to community hospitals, patients treated at an NCI-designated center were more likely to receive multimodality therapy (OR 1.62, 95% CI 1.46-1.81) and, if they received multimodality therapy, delivery of chemotherapy in the neoadjuvant compared to adjuvant setting (OR 2.82, 95% CI 2.00-3.98).

CONCLUSION

Despite increased use of multimodality therapy, it remains underutilized in all patients and especially in older patients. Receipt of multimodality therapy and neoadjuvant therapy is highly dependent on treatment at NCI-designated cancer centers.