Surgical Resection after Radiochemotherapy in Patients with Unresectable Adenocarcinoma of the Pancreas

Role of Serum Carcinoma Embryonic Antigen (CEA) Level in Localized Pancreatic Adenocarcinoma: CEA Level Before Operation is a Significant Prognostic Indicator in Patients With Locally Advanced Pancreatic Cancer Treated With Neoadjuvant Therapy Followed by Surgical Resection: A Retrospective Analysis

OBJECTIVE

The aim of the study was to identify the prognostic factors before neoadjuvant chemoradiotherapy (NCRT) in the patients with localized PDAC. Furthermore, to identify the post-surgical survival predictors of patients with LAPC.

SUMMARY OF BACKGROUND DATA

Surgical resection may occupy an important position in multimodal therapy for patients with LAPC; however, its indication and who obtains the true benefits, is still uncovered.

MATERIALS AND METHOD

From 2005 to 2017, 319 patients with localized PDAC who underwent NCRT were reviewed. Only 159 patients were diagnosed with LAPC, of these 72 patients underwent surgical resection. We examined the pre-NCRT prognostic factors in the entire cohort and conducted further subgroup analysis for evaluating the post-surgical prognostic factors in LAPC patients under the pretext of favorable local tumor control.

RESULTS

In the entire cohort, pre-NCRT CEA value was recognized as the most significant prognostic indicator by multivariate analysis. In the 72 LAPC patients who underwent surgical resection, only high CEA level was identified as an independent dismal prognostic factor before surgery. At the cut-off value: 7.2ng/mL, survival of the 15 patients whose CEA value >7.2 ng/mL was significantly unfavorable compared to those of 57 patients with <7.2 ng/mL: Median disease-specific survival time: 8.0 versus 24.0 months (P < 0.00001). Moreover, the median recurrence-free survival time of the high CEA group was only 5.4 months and there was no 1-year recurrence-free survivor.

CONCLUSIONS

CEA before NCRT is a crucial prognostic indicator for localized PDAC. Moreover, LAPC with a high CEA level, especially more than 7.2 ng/mL, should still be recognized as a systemic disease, and we should be careful to decide the indication of surgery even if tumor local control seems to be durable.

Prognostic significance of residual lymphovascular invasion after resection of locally advanced and borderline resectable pancreatic adenocarcinomas treated by neoadjuvant chemotherapy

BACKGROUND

The current study aimed to identify histological prognostic factors after resection of locally advanced (LA) and borderline (BL) pancreatic adenocarcinomas treated by neoadjuvant chemotherapy (NC).

METHODS

A retrospective review was performed of patients with LA and BL adenocarcinomas operated after NC between January 2010 and April 2018. Prognostic factors for survival were assessed by multivariate Cox analysis.

RESULTS

Of the 84 patients, 29 had BL and 55 had LA pancreatic adenocarcinomas. Seventy-five patients underwent synchronous venous resection and 57 underwent arterial resection. The median overall survival from surgery was 21.10 months (BL 23-LA 21) (95% CI: 14.8-30.3) with 1-, 3-, and 5-year overall survival rates of 73%, 32%, and 20%, respectively. Multivariate analysis identified lymphovascular invasion (LVI) as an independent prognostic factor for overall survival (HR: 2.32, 95% CI: 1.28-4.22; p = 0.004). Patients without LVI (n = 37) had superior median overall and 5-year survival rates (31.0 months [40 from diagnosis]; 39%) compared to patients with LVI (n = 47; 14.4 months [22 from diagnosis]; 7%). The absence of residual LVI was associated with major pathologic response rates (p < 0.05).

CONCLUSION

The persistence of LVI at pathology after resection of LA and BL treated by neoadjuvant chemotherapy predicts poor response and limited long-term survival.

Conversion surgery for initially unresectable pancreatic ductal adenocarcinoma following induction therapy: a systematic review of the published literature

Patients with unresectable pancreatic ductal adenocarcinoma (UR-PDAC) are traditionally treated with palliative chemotherapy. The aim of this study was to evaluate the safety and efficacy of conversion surgery for initially UR-PDAC following induction therapy. The PubMed and Embase databases were systematically searched for eligible studies published between January 2000 and October 2020. Thirty-two series involving 1270 patients with 1056 locally advanced (LA) disease and 214 distant metastases were reviewed. The median mortality and morbidity was 0% (range 0-10%) and 47.1% (range 8.6-93.3%), respectively. Lymph-node negativity, negative resection margin and pathological complete response were observed in a median of 62.9% (38.5-90.9%), 84.4% (32.8-100%) and 6.7% (0-45.8%) of the specimens. The median survival was 32 (16.4-63.9) months with a 3-year survival rate of 47% (22-80%). Meta-analysis demonstrated that conversion surgery of initially UR-PDAC was associated with a significantly improved survival (hazard ratio [HR] = 0.55; 95% confidence intervals (CI) 0.45-0.66, P < 0.001). There was no significant difference in survival between the group with LA disease and that with distant metastases after conversion surgery (HR = 0.96; 95% CI 0.72-1.28, P = 0.790). Conversion surgery improved long-term survival of patients with initially UR-PDAC who had favorable response to induction therapy.

Essential updates 2019/2020: Multimodal treatment of localized pancreatic adenocarcinoma: Current topics and updates in survival outcomes and prognostic factors

Overall survival of patients with localized pancreatic ductal adenocarcinoma (PDAC) is extremely poor. Therefore, the establishment of multimodal treatment strategies is indispensable for PDAC patients because surgical treatment alone could not contribute to the improvement of survival. In this review article, we focus on the current topics and advancement of the treatments for localized PDAC including resectable, borderline resectable, and locally advanced PDAC in accordance with the articles mainly published from 2019 to 2020. Reviewing the articles, the recent progress of multimodal treatments notably improves the prognosis of patients with localized PDAC. For resectable PDAC, neoadjuvant chemo or chemoradiation therapy, rather than upfront surgery, plays a key role, especially in patients with a large tumor, poor performance status, high tumor marker levels, peripancreatic lymph nodes metastasis, or neural invasion suspected on preoperative imaging. For borderline resectable PDAC, neoadjuvant treatments followed by surgery is a desirable approach, and maintenance of immunonutritional status during the treatments are also important. For locally advanced disease, conversion surgery has a central role in improving a survival outcome; however, its indication should be standardized.

Successful Management of Hemosuccus Pancreaticus due to Pancreatic Adenocarcinoma by Chemoradiotherapy

Management of hemosuccus pancreaticus (HP) due to pancreatic adenocarcinoma is problematic. This is the first report of the successful management of HP caused by pancreatic adenocarcinoma by chemoradiotherapy, which is a treatment option for cases with a high surgical risk that are not suitable for interventional radiology. In the present case, bloody pancreatic juice was detected in the main pancreatic duct, and anemia worsened without repeated blood transfusions. The patient ultimately underwent chemoradiotherapy comprising radiation of 3 Gy in 15 fractions concomitant with systemic chemotherapy of S-1. After the treatments, the anemia improved, and the patient was discharged on day 45.

Surgical indication for and desirable outcomes of conversion surgery in patients with initially unresectable pancreatic ductal adenocarcinoma

Aim of this review is to propose an acceptable surgical indication for conversion surgery in patients with initially unresectable (UR) pancreatic ductal adenocarcinoma (PDAC) by considering desirable outcomes, including resectability, overall survival (OS), and disease-free survival (DFS). A comprehensive literature search of PubMed was conducted through July 15, 2019. Eligible studies were those reporting on patients with UR-PDAC who underwent surgery. We excluded case reports with fewer than 10 patients, insufficient descriptions of survival data, and palliative surgery. When patients with UR-PDAC with no progression after chemo(radiation) therapy were offered surgical exploration, resectability and median survival time (MST) of those who underwent conversion surgery ranged from 20% to 69% (median, 52%) and from 19.5 to 33 months (median, 21.9 months), respectively. When conversion surgery was carried out in patients with expected margin-negative resection or with clinical response by Response Evaluation Criteria In Solid Tumors (RECIST), resectability and MST ranged from 18% to 27% (median, 20%) and from 21 to 35.3 months (median, 30 months), respectively. Among patients who underwent conversion surgery based on clinical response and decreased CA19-9 level after multimodal treatment, resectability and MST ranged from 2% to 24% (median, 4.1%) and from 24.1 to 64 months (median, 36 months), respectively. Decreased CA19-9 level was a predictor of resectability, OS and DFS by multivariate analysis. In conclusion, decision-making for conversion surgery based on clinical response and decreased CA19-9 level after multimodal treatment may be appropriate. With regard to desirable outcomes of OS and DFS, conversion surgery may provide improved survival for patients with initial UR-PDAC.

Decreased serum carbohydrate antigen 19-9 levels after neoadjuvant therapy predict a better prognosis for patients with pancreatic adenocarcinoma: a multicenter case-control study of 240 patients

Background

Carbohydrate antigen (CA) 19–9 levels after resection are considered to predict prognosis; however, the significance of decreased CA19–9 levels after neoadjuvant therapy has not been clarified. This study aimed to define the prognostic significance of decreased CA19–9 levels after neoadjuvant therapy in patients with pancreatic adenocarcinoma.

Methods

Between 2001 and 2012, 240 consecutive patients received neoadjuvant therapy and subsequent resection at seven high-volume institutions in Japan. These patients were divided into three groups: Normal group (no elevation [≤37 U/ml] before and after neoadjuvant therapy), Responder group (elevated levels [> 37 U/ml] before neoadjuvant therapy but decreased levels [≤37 U/ml] afterwards), and Non-responder group (elevated levels [> 37 U/ml] after neoadjuvant therapy). Analyses of overall survival and recurrence patterns were performed. Uni- and multivariate analyses were performed to clarify the clinicopathological factors influencing overall survival. The initial metastasis sites were also evaluated in these groups.

Results

The Responder group received a better prognosis than the Non-responder group (3-year overall survival: 50.6 and 41.6%, respectively, P = 0.026), but the prognosis was comparable to the Normal group (3-year overall survival: 54.2%, P = 0.934). According to the analysis of the receiver operating characteristic curve, the CA19–9 cut-off level defined as no elevation after neoadjuvant therapy was ≤103 U/ml. The multivariate analysis revealed that a CA19–9 level ≤ 103 U/ml, (P = 0.010, hazard ratio: 1.711; 95% confidence interval: 1.133–2.639), tumor size ≤27 mm (P = 0.040, 1.517; (1.018–2.278)), a lack of lymph node metastasis (P = 0.002, 1.905; (1.276–2.875)), and R0 status (P = 0.045, 1.659; 1.012–2.627) were significant predictors of overall survival. Moreover, the Responder group showed a lower risk of hepatic recurrence (18%) compared to the Non-responder group (31%), though no significant difference in loco-regional, peritoneal or other distant recurrence were observed between groups (P = 0.058, P = 0.700 and P = 0.350, respectively).

Conclusions

Decreased CA19–9 levels after neoadjuvant therapy predicts a better prognosis, with low incidence of hepatic recurrence after surgery.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5460-4) contains supplementary material, which is available to authorized users.

Preoperative Imaging Evaluation after Downstaging of Pancreatic Ductal Adenocarcinoma: A Multi-Center Study

Introduction: Evaluation of pancreatic ductal adenocarcinoma (PDAC) after chemoradiotherapy downstaging is challenging due to computed tomography (CT) overestimation of tumor extension and residual vascular involvement, limiting access to surgery to some patients with potentially resectable tumors. With this study, we wanted to assess which radiological findings are most reliable at pre-operative imaging in the evaluation of PDAC after chemoradiotherapy in order to achieve complete resection. Methods: We retrospectively enrolled 71 patients with locally advanced and borderline resectable PDAC who underwent neoadjuvant chemoradiotherapy. Pre-operative CT or magnetic resonance (MR) have been evaluated by three radiologists to assess major qualitative and quantitative parameters of lesions. Accuracy, sensitivity, and specificity compared to anatomopathological results were evaluated for each parameter. Cohen’s K-coefficient has been calculated to evaluate the inter-observer agreement (IOA). Both single and consensus lecture have been tested. Different dimensional cut-offs were tested to categorize tumors according to their major axis and to compare with anatomopathological diameter, tumor persistence, and margin infiltration. Results: A 25 mm cut-off was 67% sensitive, 90% specific, and 77% accurate in assessing real tumor dimension. 25 mm cut-off reported a 64% sensitivity, 78% specificity, and 69% accuracy in assessing R0 resection. Each 5 mm increment of major axis dimension there is an odds ratio (OR) 1.79 (95% CI 1.13–2.80, p = 0.012) for R+ resection. Imaging presence of the perivascular cuff is not associated with tumor persistence and resection margin infiltration (p = 0.362). Lesion enhancement and pattern homogeneity were not accurate in determining tumor persistence. IOA was generally poor to fair, except for >25 mm cut-off classification where IOA was moderate. Diagnostic accuracy is superior in consensus lecture rather than single lecture. Conclusion: Imaging methods tend to underestimate PDAC resectability after neoadjuvant-CRT. IOA is poor to fair in evaluating most of the qualitative parameters of downstaged pancreatic adenocarcinoma. Surgery should be considered for downstaged borderline resectable PDACs, independently from perivascular cuff presence, especially for tumors smaller than 25 mm.

Pancreatic Adenocarcinoma Staging in the Era of Preoperative Chemotherapy and Radiation Therapy

Pancreatic ductal adenocarcinoma (PDA) remains among the most challenging malignancies to treat. At diagnosis, the tumor often already extends beyond the confines of the pancreas, spreading to an extent such that primary surgery with curative intent is very rarely feasible. Considerable momentum is now being given to a treatment strategy involving neoadjuvant chemotherapy or chemotherapy and radiation therapy in patients with nonmetastatic PDA. The main advantage of this strategy is better selection of patients likely to benefit from curative-intent surgery through the achievement of negative resection margins. Patients with rapidly progressive disease are identified and are spared ineffective surgery with its attendant morbidity. Neoadjuvant therapy can downstage tumors classified as locally advanced at initial imaging studies to resectable tumors. However, the imaging study evaluation of the response to neoadjuvant therapy is extremely complex. Thus, the diagnostic performance of imaging studies is not sufficient to ensure the accurate selection of patients in whom negative-margin resection is likely to be achieved. More specifically, standard criteria for predicting vascular invasion, based on the amount of tumor-vessel contact, are not valid after neoadjuvant therapy. ^©RSNA, 2018.

Nanotechnologies in Pancreatic Cancer Therapy

Pancreatic cancer has been classified as a cancer of unmet need. After diagnosis the patient prognosis is dismal with few surviving over 5 years. Treatment regimes are highly patient variable and often the patients are too sick to undergo surgical resection or chemotherapy. These chemotherapies are not effective often because patients are diagnosed at late stages and tumour metastasis has occurred. Nanotechnology can be used in order to formulate potent anticancer agents to improve their physicochemical properties such as poor aqueous solubility or prolong circulation times after administration resulting in improved efficacy. Studies have reported the use of nanotechnologies to improve the efficacy of gemcitabine (the current first line treatment) as well as investigating the potential of using other drug molecules which have previously shown promise but were unable to be utilised due to the inability to administer through appropriate routes-often related to solubility. Of the nanotechnologies reported, many can offer site specific targeting to the site of action as well as a plethora of other multifunctional properties such as image guidance and controlled release. This review focuses on the use of the major nanotechnologies both under pre-clinical development and those which have recently been approved for use in pancreatic cancer therapy.

Thermally triggered theranostics for pancreatic cancer therapy

Hybrid iron oxide-gold nanoparticles (HNPs) show the ability to bind drugs onto their surface with a triggered release at elevated temperatures. The iron oxide core allows for diagnostic imaging whilst heating of the gold shell upon laser irradiation reverses drug binding. This study exploits the reversible binding of novel polyamine based drugs in order to provide a specific and effective method for pancreatic cancer treatment. Here we used a novel bisnaphthalamido (BNIP) based drug series. Our hybrid nanoparticles (50 nm) showed the ability to load drugs onto their surface (3 : 1 : 0.25, drug : Fe : Au). By exploiting the surface-to-drug electrostatic interaction of a range of BNIP agents, heat triggered drug release was achieved. A 12-fold reduction in IC₅₀ after 24 h in vitro and a 5-fold reduction of tumour retardation in vivo compared with free drug in pancreatic models after treatment were achieved with the HNP-formulation and laser irradiation. This heat activated system could provide a key platform for future therapeutic strategies.

Clinical effects of chemoradiotherapy in pursuit of optimal treatment of locally advanced unresectable pancreatic cancer

OBJECTIVE

The treatment of locally advanced unresectable pancreatic cancer remains extremely challenging, particularly as the efficacy of concurrent chemoradiotherapy (CRT) remains unclear.

METHODS

We studied 93 patients (8.0%) with locally advanced unresectable pancreatic cancer without distant metastases from among a total group of 1168 patients who were diagnosed with pancreatic cancer from March 2005 to November 2015 at the Kochi Health Sciences Center, Kochi, Japan. We therefore evaluated the clinical efficacy of CRT in patients with locally advanced unresectable pancreatic cancer.

RESULTS

Of the 93 patients with locally advanced unresectable pancreatic cancer, 35 patients (37.6%) were subsequently classified as having resectable disease following CRT. The median overall survival of patients who received CRT alone for locally advanced unresectable pancreatic cancer was 8.0 months, and all died within 3 years. On the other hand, the overall 1-, 3- and 5-year survival rates in patients who were reclassified as having resectable tumour after CRT were 71.3%, 39.2% and 23.5%, respectively. Our pathological assessments after surgical resection suggested that CRT might be associated with a significant reduction in the risk of lymph node metastases in patients with locally advanced unresectable pancreatic cancer.

CONCLUSION

The results of this study suggested that CRT is clinically effective in improving survival, particularly in association with the resultant possibility of curative resection. Advances in knowledge: The best treatment strategy for patients with locally advanced unresectable pancreatic cancer is the subject of considerable debate, and CRT is only recommended if cancer has only grown around the pancreas without any distant metastases.

CT evaluation after neoadjuvant FOLFIRINOX chemotherapy for borderline and locally advanced pancreatic adenocarcinoma

AIM

To assess anatomic changes on computed tomography (CT) after neoadjuvant FOLFIRINOX (5-fluorouracil/leucovorin/irinotecan/oxaliplatin) chemotherapy for secondary resected borderline resectable (BR) and locally advanced (LA) pancreatic adenocarcinoma and their accuracy to predict resectability and pathological response.

METHODS

Thirty-six patients with secondary resected BR/LA pancreatic adenocarcinoma after neoadjuvant FOLFIRINOX chemotherapy (± chemoradiotherapy) were retrospectively included. Two radiologists reviewed baseline and pre-surgical CTs in consensus. NCCN (National Comprehensive Cancer Network) classification, largest axis, product of the three axes (P3A), and arterial/venous involvement were studied and compared to pathological response and resection status and to disease-free survival (DFS).

RESULTS

Thirty-one patients had R0 resection, including only six exhibiting a downstaging according to the NCCN classification. After treatment, the largest axis and P3A decreased (P < 0.0001). The pre-surgical largest axis and P3A were smaller in case of R0 resection (P = 0.019/P = 0.021). The largest axis/P3A variations were higher in case of complete pathological response (P = 0.011/P = 0.016). A decrease of the arterial/venous involvement was not able to predict R0 or ypT0N0 (P > 0.05). Progression of the vascular involvement was seen in two (5 %) patients and led to a shorter DFS.

CONCLUSION

In BR/LA pancreatic adenocarcinoma after the neoadjuvant FOLFIRINOX regimen (± chemoradiotherapy), significant tumour size decreases were observed on CT. However, CT staging was not predictive of resectability and pathological response.

KEY POINTS

• Significant tumour size decreases were observed on CT after FOLFIRINOX (± chemoradiotherapy). • CT is not able to predict R0 resection accurately after FOLFIRINOX (± chemoradiotherapy). • CT is not able to predict complete response accurately after FOLFIRINOX (± chemoradiotherapy). • Even with a stable NCCN classification, BR/LA pancreatic adenocarcinoma could have R0 resection.

Radiological evaluation of response to neoadjuvant treatment in pancreatic cancer

Neoadjuvant chemotherapy has become common practice in the management of patients with non-metastatic pancreatic adenocarcinoma. This strategy helps better select patients who would benefit from surgical resection and also increase the number of patients amenable to surgical resection whose tumor seemed too locally advanced on initial imaging. However, several studies have shown that the radiological evaluation of the response after neoadjuvant therapy is difficult for pancreatic carcinoma. This article reviews the scientific basis of neoadjuvant therapy for non-metastatic pancreatic cancer and provides an update on tumor response evaluation with imaging after neoadjuvant treatment.

CA19-9 Normalization During Pre-operative Treatment Predicts Longer Survival for Patients with Locally Progressed Pancreatic Cancer

BACKGROUND

Compared to the widely adopted 2-4 months of pre-operative therapy for patients with borderline resectable (BR) or locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC), our institution tends to administer a longer duration before considering surgical resection. Using this unique approach, the aim of this study was to determine pre-operative variables associated with survival.

METHODS

Records from patients with BR/LA PDAC who underwent attempt at surgical resection from 1992-2014 were reviewed.

RESULTS

After a median duration of 6 months of pre-operative treatment, 109 patients with BR/LA PDAC (BR 63, LA 46) were explored; 93 (85.3 %) underwent pancreatectomy. Those who received at least 6 months of pre-operative treatment had longer median overall survival (OS) than those who received less (52.8 vs. 32.1 months, P = 0.044). On multivariate analysis, pre-operative treatment duration was the strongest predictor of survival (hazard ratio (HR) 4.79, P = 0.043). However, OS was similar in those whose CA19-9 normalized regardless of whether they received more or less than 6 months of chemotherapy (71.4 vs. 101.8 months, P = 0.930).

CONCLUSIONS

Pre-operative CA19-9 decline can guide treatment duration in patients with BR/LA PDAC. We endorse 6 months of therapy except in those patients whose values normalize, where surgery can be considered after a shorter course.

Treatment of Locally Advanced Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is increasingly common and a leading cause of cancer-related mortality. Surgery remains the only possibility for cure. Upwards of 40% of patients present with locally advanced PDAC (LA-PDAC), where management strategies continue to evolve. In this review, we highlight current trends in neoadjuvant chemotherapy, surgical resection, and other multimodality approaches for patients with LA-PDAC. Despite promising early results, additional work is needed to more accurately and appropriately tailor treatment for patients with LA-PDAC.

Potential of hybrid iron oxide–gold nanoparticles as thermal triggers for pancreatic cancer therapy

Laser irradiation of hybrid nanoparticles in biological conditions for future application in pancreatic cancer therapy.

Inverse Probability of Treatment Weighting Analysis of Upfront Surgery Versus Neoadjuvant Chemoradiotherapy Followed by Surgery for Pancreatic Adenocarcinoma with Arterial Abutment

Combined arterial resection during pancreatectomy can be a challenging treatment, and outcome would be more favorable if the tumor becomes technically removable from the artery. Neoadjuvant chemoradiotherapy (NACRT) is expected to achieve locoregional control and enable margin-negative resection. To investigate the effects of NACRT in patients with pancreatic adenocarcinoma (PDAC) which were deemed borderline resectable through preoperative imaging due to abutment of the major artery, including the superior mesenteric artery (SMA) or common hepatic artery (CHA), but were still considered to be technically removable. In the current study, comparisons were make between 71 patients who underwent upfront surgery and 21 patients who underwent NACRT followed by surgery in the strategy to preserve the artery, using unmatched and inverse probability of treatment weighting analysis (UMIN000017115). Fifty patients in the upfront surgery group and 18 in the NACRT group underwent curative resection (70% vs 86%, respectively; P = 0.16). The results of the propensity score weighted logistic regressions indicated that the incidences of pathological lymph node metastasis and a pathological positive resection margin were significantly lower in the NACRT group (odds ratio, 0.006; P < 0.001 and odds ratio, 0.007; P < 0.001, respectively). Among the propensity-score matched patients, the estimated 1- and 2-year survival rates in the upfront surgery group were 66.7% and 16.0%, respectively, and those in the NACRT group were 80.0% and 65.2%, respectively. In conclusion, it was suggested that chemoradiotherapy followed by surgery provided clinical benefits in patients with PDACs in contact with the SMA or CHA.

Pancreaticoduodenetomy combined with hepatic artery resection following preoperative hepatic arterial embolization

BACKGROUND

The possibility of resection for locally advanced pancreatic ductal adenocarcinoma (PDAC) with involvement of hepatic or superior mesenteric artery is low. The treatment strategy for these locally advanced PDAC needs to be elucidated.

METHODS

We retrospectively reviewed the medical records of 107 patients undergoing pancreaticoduodenectomy for PDAC between 2007 and 2012. Among these patients, seven patients who had unresectable PDAC because of cancer involvement of hepatic artery underwent preoperative hepatic arterial embolization and subsequent pancreaticoduodenectomy combined with resection of hepatic artery without reconstruction (PDCAR). We specifically focused on these seven patients to clarify the benefit and drawback of PDCAR.

RESULTS

Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels on 1 day after hepatic arterial embolization increased, but returned to baseline before pancreaticoduodenectomy. There was no arterial embolization-related complication before surgery. Serum ALT and AST levels increased 1 day after surgery, but thereafter returned to baseline. Although postoperative morbidity such as hepatic infarction was observed in one case, there were no in-hospital deaths. The median survival time was 12.6 months and 5-year survival rate was 19%.

CONCLUSION

Preoperative hepatic arterial embolization and subsequent PDCAR might be a feasible procedure in selected patients with unresectable locally advanced PDAC with hepatic artery involvement.

Multidisciplinary neoadjuvant management for potentially curable pancreatic cancer

Pancreatic adenocarcinoma remains the fourth leading cause of cancer mortality in the U.S. Despite advances in surgical technique, radiotherapy technologies, and chemotherapeutics, the 5-year survival rate remains approximately 20% for the 15% of patients who are eligible for surgical resection. The majority of this group suffers metastatic recurrence. However, despite advances in therapies for patients with advanced pancreatic cancer, only surgery has consistently proven to improve long-term survival. Various combinations of chemotherapy, biologic-targeted therapy, and radiotherapy have been evaluated in different settings to improve outcomes. In this context, a neoadjuvant (preoperative) treatment strategy offers numerous potential benefits: (1) ensuring delivery of early, systemic therapy, (2) improving selection of patients for surgical therapy with truly localized disease, (3) potential downstaging of the neoplasm facilitating a negative margin resection in patients with locally advanced disease, and (4) providing a superior clinical trial mechanism capable of rapid assessment of the efficacy of novel therapeutics. This article reviews the recent trends in the management of pancreatic adenocarcinoma, with a particular emphasis on a multidisciplinary neoadjuvant approach to treatment.

Resection of Borderline Resectable and Locally Advanced Pancreatic Adenocarcinomas after Neoadjuvant Chemotherapy

OBJECTIVE

To report the outcomes of surgical resection of borderline resectable (BL) and locally advanced (LA) 'unresectable' pancreatic cancer after neoadjuvant chemotherapy.

METHODS

A review of a prospectively maintained database for pancreatic resections was undertaken to identify patients undergoing resection for BL and LA pancreatic cancer after neoadjuvant chemotherapy between January 2007 and December 2012. Clinicopathological, surgical and survival outcomes were analyzed.

RESULTS

A total of 45 patients with LA (n = 34) or BL cancer (n = 11) underwent surgery after a mean (± SD) of 7 ± 4 preoperative chemotherapy cycles. Ninety-day mortality was 6.7%, and overall morbidity was 33.3%. An R0 resection was achieved in 34 patients, and 4 patients showed a complete pathological response. Overall median postoperative survival was 17 months (21 after the start of neoadjuvant treatment). Overall and disease-free survival was 74.9 and 43.6% at 1 year and 21.2 and 10.3% at 3 years, respectively. In BL cancer patients, the 3-year survival was significantly higher compared to that of LA cancer patients (p = 0.02).

CONCLUSIONS

Curative intent resection in BL and LA cancer patients after neoadjuvant chemotherapy can be achieved with reasonable mortality and morbidity and an encouraging 3-year survival. After neoadjuvant therapy, resection provides a better overall survival for BL compared to LA cancer patients.

Neoadjuvant therapy for non-metastatic pancreatic ductal adenocarcinoma

Treatment of pancreatic cancer is increasingly multimodal, with patients receiving chemotherapy, radiation, and surgical extirpation in hope of long-term cure. There is ongoing debate over the timing, sequence, and necessity of these treatments as they pertain to the spectrum of local-regional disease. Current guidelines support a neoadjuvant strategy in patients with locally advanced and borderline resectable disease. Although there is currently no high-level evidence to recommend neoadjuvant therapy for all patients, there are data to suggest that wider application of neoadjuvant therapy may be beneficial. Random-assignment prospective trials are ongoing. In this review we examine the literature addressing a neoadjuvant approach to potentially resectable, borderline resectable, and locally advanced pancreatic cancer and highlight the outcomes of preoperative emergence of latent metastatic disease, attempted resection rates, margin negative resection rates, and pathologic response to treatment.

Role of adjuvant surgery in initially unresectable pancreatic cancer after long-term chemotherapy or chemoradiation therapy: survival benefit?

BACKGROUND

The purpose of the present study was to analyze the survival benefit and safety of adjuvant surgery in patients with initially unresectable pancreatic cancer following chemo(radio)therapy.

METHODS

The 130 patients with unresectable pancreatic cancer treated during 2006 to 2013 were divided into a study group (15 patients) with planned adjuvant surgery, and a control group (115 patients with locally advanced disease) without adjuvant surgery.

RESULTS

The study group of 15 patients had shrunken tumor, decreased tumor marker, and maintained performance status after 9 months (range 5-18 months) of chemo(radio)therapy. Thirteen patients had curative resection and two patients were not resected. The remaining controls of 115 patients did not undergo surgical resection due to poor response to chemo(radio)therapy or performance status. The median survival time in the study group was better than in the control group (36 vs. 9 months, P < 0.001). The mortality and morbidity rates in the study group were 0% and 46% respectively, in spite of concomitant organ resections in 77%.

CONCLUSION

Patients who had adjuvant surgery had significant improvement of survival without increase in morbidity and mortality, relative to patients with locally advanced disease. Thus, adjuvant surgery may provide the promising results in this group who responded favorably to initial chemo(radio)therapy in unresectable pancreatic cancer.

FOLFIRINOX for locally advanced pancreatic adenocarcinoma: results of an AGEO multicenter prospective observational cohort

BACKGROUND

First-line treatment with FOLFIRINOX significantly increases overall survival (OS) in patients with metastatic pancreatic adenocarcinoma (PA) compared with gemcitabine. The aim of this observational cohort was to evaluate the tolerability and efficacy of this regimen in unresectable locally advanced PA (LAPA).

PATIENTS AND METHODS

From February 2010 to February 2012, all consecutive patients from 11 French centers treated by FOLFIRINOX for a histologically proven LAPA were prospectively enrolled. Unresectability was defined independently by each center's multidisciplinary staff at diagnosis. Absence of metastatic disease was confirmed by chest-abdomen-pelvis computed tomography scan. FOLFIRINOX was delivered every 2 weeks as previously reported until progressive disease, major toxicity, or consolidation treatment by radiotherapy and/or surgery.

RESULTS

Seventy-seven patients were enrolled. They received a median number of five cycles (1-30). Grade 3-4 toxicities were neutropenia (11 %), nausea (9 %), diarrhea (6 %), fatigue (6 %), and anemia (1 %). Grade 2-3 sensory neuropathy occurred in 25 % of patients. No toxic death was reported and only 6 % of patients had to stop treatment because of toxicity. Disease control rate was 84 with 28 % of objective response (Response Evaluation Criteria in Solid Tumors). Seventy-five percent of patients received a consolidation therapy: 70 % had radiotherapy and 36 % underwent a surgical resection, with a curative intent. Within the whole cohort, 1-year OS rate was 77 % (95 % CI 65-86) and 1-year progression-free survival rate was 59 % (95 % CI 46-70).

CONCLUSION

First-line FOLFIRINOX for LAPA seems to be effective and have a manageable toxicity profile. These promising results will have to be confirmed in a phase III randomized trial.

Gemcitabine-based chemoradiotherapy followed by surgery for borderline resectable and locally unresectable pancreatic ductal adenocarcinoma: significance of the CA19-9 reduction rate and intratumoral human equilibrative nucleoside transporter 1 expression

OBJECTIVES

This study aimed to evaluate the efficacy of gemcitabine-based chemoradiotherapy followed by surgery (gem-CRTS) for pancreatic ductal adenocarcinoma (PDAC) for borderline resectable (BR) and locally unresectable (UR) tumors.

METHODS

One hundred patients with PDAC who underwent the gem-CRTS protocol were classified into 3 groups, namely, resectable (R; 14), BR (44), and UR (42). After chemoradiotherapy, the patients were reassessed for curative-intent resection.

RESULTS

At reassessment, distant metastases became apparent in 27% of R patients, in 12% of BR patients, and in 18% of UR patients. The multivariate analysis of preoperative factors indicated that the CA19-9 reduction rate was an independent prognostic factor in the BR group. Among reassessed patients, the resection rate was 63.6% in R, 83.7% in BR, and 50.0% in UR patients. In 63 patients that underwent curative-intent resection, the 3-year survival rate was 83.3% in R, 33.0% in BR, and 7.8% in UR patients. Using multivariate analysis, the independent prognostic factor was found to be the surgical margin in BR patients and human equilibrative nucleoside transporter 1 expression in UR patients.

CONCLUSIONS

We consider that our gem-CRTS protocol, even for locally UR PDAC, allows for the identification of candidates for aggressive resection at the time of reassessment and improved prognosis in the patients with positive human equilibrative nucleoside transporter 1 expression.

Performance characteristics of endoscopic ultrasound in the staging of pancreatic cancer: a meta-analysis

CONTEXT

The optimal approach to pre-operative imaging assessment of pancreatic cancer is unknown.

OBJECTIVE

The aim of this meta-analysis was to assess accuracy and performance characteristics of EUS in determining nodal staging, vascular invasion, and prediction of resectability of pancreatic cancer. A secondary aim was to perform head to head comparison of performance characteristics between EUS and CT for nodal staging, vascular invasion and resectability.

DESIGN

Data from EUS studies were pooled according to bivariate generalized random effects model. Pooled estimates for CT were obtained from studies which performed head to head comparison between EUS and CT.

PATIENTS

Patients with pancreatic cancer undergoing pre-operative imaging assessment.

INTERVENTION

EUS.

MAIN OUTCOME MEASURE

Pooled sensitivity, specificity, positive and negative predictive values of EUS for nodal staging, vascular invasion and resectability.

RESULTS

Forty-nine studies were considered of which 29 met inclusion criteria with a total of 1,330 patients. Pooled summary estimates for EUS-nodal staging were 69% for sensitivity and 81% for specificity. For vascular invasion, sensitivity was 85% and specificity was 91%. The sensitivity and specificity for resectability was 90% and 86%, respectively. CT scan showed lower sensitivity than EUS for nodal staging (24% vs. 58%) and vascular invasion (58% vs. 86%); however, the specificities for nodal staging (88% vs. 85%) and vascular invasion (95% vs. 93%) were comparable in studies where both imaging techniques were performed. The sensitivity and specificity of CT in determining resectability (90% and 69%) was similar to that of EUS (87% and 89%).

CONCLUSIONS

EUS is an accurate pre-operative tool in the assessment of nodal staging, vascular invasion and resectability in patients with pancreatic cancer.

Pancreaticoduodenectomy following chemoradiotherapy for locally advanced adenocarcinoma of the pancreatic head

OBJECTIVES

The aim of this study was to assess oncological outcomes in patients treated with pancreaticoduodenectomy for advanced pancreatic head adenocarcinoma after preoperative chemoradiotherapy and to compare these with outcomes in patients treated with surgery alone.

METHODS

From 2004 to 2009, patients treated with pancreaticoduodenectomy for pancreatic head adenocarcinoma were included in a retrospective comparative study. Patients with locally advanced adenocarcinoma were treated with preoperative chemoradiotherapy (CRT group) and were compared with those treated with surgery alone (SURG group).

RESULTS

A total of 111 patients were included; these comprised 72 patients in the SURG group and 39 patients in the CRT group. The median follow-up was 21 months. Patients in the CRT group presented with a more advanced tumoral status. Microscopic resection rates were similar in both groups, but nodal status and vascular or lymphatic emboli were lower in the CRT group. At 3 years, the SURG and CRT groups exhibited similar overall (36% and 51%, respectively) and disease-free (35% and 37%, respectively) survival (P = 0.10).

CONCLUSIONS

In patients with advanced pancreatic head adenocarcinoma, a good response after preoperative chemoradiotherapy results in a survival rate similar to that in patients treated with surgery alone in whom the initial prognosis is better.

Role of adjuvant surgery for patients with initially unresectable pancreatic cancer with a long-term favorable response to non-surgical anti-cancer treatments: results of a project study for pancreatic surgery by the Japanese Society of Hepato-Biliary-Pancreatic Surgery

PURPOSE

A multicenter survey was conducted to explore the role of adjuvant surgery for initially unresectable pancreatic cancer with a long-term favorable response to non-surgical cancer treatments.

METHODS

Clinical data including overall survival were retrospectively compared between 58 initially unresectable pancreatic cancer patients who underwent adjuvant surgery with a favorable response to non-surgical cancer treatments over 6 months after the initial treatment and 101 patients who did not undergo adjuvant surgery because of either unchanged unresectability, a poor performance status, and/or the patients' or surgeons' wishes.

RESULTS

Overall mortality and morbidity were 1.7 and 47 % in the adjuvant surgery group. The survival curve in the adjuvant surgery group was significantly better than in the control group (p < 0.0001). The propensity score analysis revealed that adjuvant surgery was a significant independent prognostic variable with an adjusted hazard ratio (95 % confidence interval) of 0.569 (0.36-0.89). Subgroup analysis according to the time from initial treatment to surgical resection showed a significant favorable difference in the overall survival in patients who underwent adjuvant surgery over 240 days after the initial treatment.

CONCLUSION

Adjuvant surgery for initially unresectable pancreatic cancer patients can be a safe and effective treatment. The overall survival rate from the initial treatment is extremely high, especially in patients who received non-surgical anti-cancer treatment for more than 240 days.

Conditionally replicative adenoviral vectors for imaging the effect of chemotherapy on pancreatic cancer cells

Pancreatic cancer has a poor prognosis after complete macroscopic resection combined with chemotherapy. Even after neoadjuvant chemotherapy, R0 resection is often not possible. Moreover, current imaging techniques cannot reliably distinguish viable cancer cells from scar tissue at the resectional margin. We investigated the use of a conditionally replicative adenovirus (CRAd), Ad5/3Cox2CRAd-ΔE3ADP-Luc, for imaging the effects of chemotherapy. The CRAd infectivity of pancreatic cancer cells was enhanced by a chimeric Ad5/3 fiber, E1A expression was under the control of the Cox2 promoter, and the luciferase gene was inserted adjacent to the adenovirus death protein (ADP) gene. Subcutaneous xenografts of the pancreatic cancer cell line MiaPaCa-2 were established in 24 BALB/c nu/nu mice. When xenografts reached a diameter of 4-6 mm (day 1), the mice were injected i.p. with either PBS (group A; n = 12) or 1000 mg/kg gemcitabine (group B; n = 12), weekly. On days 19, 26, 33, and 40, CRAd were injected intratumorally into three mice in groups A and B. Bioluminescence was imaged 72 h after CRAd injection, and gross tumor volumes were measured then tumors were removed for ex vivo histopathology using H&E and Ki-67 staining. Correlations between gross tumor volume, pathological evaluation of the percentage of viable tumor area, and CRAd bioluminescence were analyzed. Bioluminescence correlated closely with the percentage of viable tumor area (R = 0.96), but not with gross tumor volume (R = 0.31). Therefore, CRAds might be reliable imaging tools for monitoring chemotherapy in pancreatic cancer, and could improve our ability to distinguish viable tumor cells from scar tissue.

An evaluation of the accuracy of CT when determining resectability of pancreatic head adenocarcinoma after neoadjuvant treatment

BACKGROUND

To evaluate the accuracy of MDCT for determination of resectability R0 after neoadjuvant therapy in patients with pancreatic head adenocarcinoma locally advanced.

METHODS

From January 2005 to December 2010, 80 patients with pancreatic head adenocarcinoma underwent multidetector CT before surgery. Of these, 38 patients received neoadjuvant therapy because tumor was considered locally advanced on baseline CT scan. We retrospectively correlated imaging interpretations with operative and histological data and compared results in patients without (control group) or with (neoadjuvant group) preoperative treatment.

RESULTS

41/42 patients in control group and 31/38 patients in neoadjuvant group finally had curative resection. While resection R0 is similar in both groups (83% and 81%), CT accuracy in determining resectability R0 was significantly decreased in neoadjuvant group (58% versus 83%; p=0.039). CT scan specificity was significantly lower after neoadjuvant therapy (52% versus 88% in control group) due to an overestimation of vascular invasion: 12/31 patients with complete resection in neoadjuvant group were evaluated at high risk of incomplete resection on CT scan. Tumor size tends to be underestimated in control group (-2mm) and overestimated in neoadjuvant group (+10mm). T-staging accuracy was decreased in neoadjuvant group (39% versus 78% in control group; p=0.002).

CONCLUSION

Neoadjuvant therapy significantly decreases the accuracy of CT scan in determining operability, T-staging, and resectability R0 of pancreatic head carcinoma. Overestimation of tumor size and vascular invasion significantly reduces CT scan specificity after preoperative treatment.

Prospective efficacy and safety study of neoadjuvant gemcitabine with capecitabine combination chemotherapy for borderline-resectable or unresectable locally advanced pancreatic adenocarcinoma

BACKGROUND

To determine the safety and efficacy of neoadjuvant gemcitabine/capecitabine followed by surgery for the treatment of locally advanced pancreatic adenocarcinoma (LAPC).

METHODS

Patients with histologically confirmed LAPC were given 3-6 cycles of fixed-dose rate gemcitabine/capecitabine every 3 weeks. At the end of chemotherapy, patients were restaged and underwent surgery if the disease was not classified as unresectable. Our institutional criteria were used to classify respectability, which was recategorized on the basis of National Comprehensive Cancer Network (NCCN) criteria retroactively. The primary end point was rate of microscopic curative resection.

RESULTS

Forty-three eligible patients (18 with borderline resectable disease and 25 with unresectable disease on the basis of NCCN criteria) were enrolled. The radiologic response rate was 18.6%. Grade three or worse adverse events were mainly hand-foot syndrome (11%), and there were no grade four adverse events. Surgery was performed in 17 patients (39.5%); pathologic curative resection (R0) was achieved in 14 patients (32.5%) among total 43 patients, and 82.3% (14/17) among the 17 resected patients. With 43-month follow-up, the median overall was 16.6 months with a median progression-free survival of 10.0 months. Median overall survival was 23.1 months in patients who underwent surgery and 13.2 months in patients who could not complete the surgery (P = .017).

CONCLUSION

A subset of patients with borderline or unresectable pancreatic cancer could be performed curative tumor resection after neoadjuvant chemotherapy. Some patients might be benefit on survival from neoadjuvant chemotherapy after surgical resection.

Pancreatoduodenectomy following neoadjuvant chemoradiation therapy in uncinate process pancreatic cancer

OBJECTIVE

The objective of the study was to delineate surgical outcomes of pancreatoduodenectomy following neoadjuvant concurrent chemoradiation therapy (CCRT) in uncinate process pancreatic cancer (UPC).

METHODS

We reviewed 97 patients with resected usual pancreatic head cancer (PHC) and UPC and analyzed clinicopathologic characteristics and survival outcomes of PHC and UPC with a review of the reported literature regarding UPC.

RESULTS

Twenty-five patients (27.8%) had UPC, and 72 patients had PHC. Pylorus-preserving pancreatoduodenectomy was performed in 67 patients (69.1%) and conventional pancreatoduodenectomy in 28 patients (28.9%), and 2 patients needed total pancreatectomies. When comparing UPCs with PHCs, less frequent jaundice (P = 0.009) and more advanced stages of cancers at the time of diagnosis (linear-to-linear association, P = 0.03) were found in UPCs, and CCRT was administered more frequently in UPCs (P = 0.013). Survival outcomes between PHC and UPC were similar, with median survival rates of 25.9 and 30.5 months, respectively (P = 0.702). In addition, disease-free survival was similar between the 2 groups (15.6 and 15.2 months, respectively; P = 0.4503). Our oncologic outcome of pancreatectomy for UPC is likely to be more acceptable compared with those previously reported in the literature.

CONCLUSIONS

Although UPCs are found in relatively advanced clinical stages, favorable oncologic outcomes may be obtained by pancreatectomy following preoperative CCRT.

NeoGemTax: gemcitabine and docetaxel as neoadjuvant treatment for locally advanced nonmetastasized pancreatic cancer

BACKGROUND

About 30% of patients with pancreatic cancer suffer from locally advanced nonmetastatic carcinoma at the time of diagnosis. We conducted a prospective phase II clinical trial using neoadjuvant chemotherapy, consisting of gemcitabine and docetaxel, to assess the rate of complete radical resection and overall survival.

METHODS

Gemcitabine (900 mg/m2) and docetaxel (35 mg/m2) were given on days 1, 8, and 15 of a 28-day cycle. Two cycles were administered for a preoperative treatment duration of 8 weeks. Patients experiencing tumor regression or stable disease and improved performance status subsequently underwent surgical exploration and pancreatic resection, if feasible. All patients were followed postoperatively to assess long-term survival.

RESULTS

A total of 25 patients were eligible and included in the intent-to-treat and evaluable population. Thirteen patients had unresectable disease at inclusion and 12 patients had borderline resectable pancreatic cancer. Finally, 8 of 25 (32%) patients underwent resection after neoadjuvant chemotherapy; 7 (87%) of these patients had R0 resection. The median overall survival of patients who underwent resection was 16 months (95% confidence interval [CI], 8-24 months) compared to 12 months (95% CI, 8-16 months) for those without resection (p=0.276). The median recurrence-free survival rate after resection was 12 months (95% CI, 2-21 months).

CONCLUSIONS

NeoGemTax was safe and resection was feasible in a number of patients after systemic neoadjuvant treatment. Further randomized clinical trials are needed to identify novel multimodal regimens that would be able to increase the percentage of patients undergoing curative pancreatic cancer surgery despite advanced tumor stage at the time of diagnosis.

Vascular reconstruction during pancreatoduodenectomy for ductal adenocarcinoma of the pancreas improves resectability but does not achieve cure

OBJECTIVE

Combined vascular and pancreatic resection improves long-term survival of patients suffering from ductal adenocarcinoma of the pancreatic head. This study was designed to compare the results of surgical resection in patients with pancreatic cancer with or without vascular resection. Late 10-year disease-free survival was considered as an indicator of patients' disease cure.

METHODS

A total of 149 consecutive patients have undergone pancreatoduodenectomy without vascular resection (group 1: 82 patients), with isolated venous resection (group B: 67 patients), or with arterial and/or venous resection (group C: 8 patients).

RESULTS

The duration of surgery and blood losses were significantly more important in groups B and C compared with group A; however, postoperative morbidity and mortality rates were similar. R1 resection was significantly more frequent in groups B (42%) and C (50%) compared with group A (13%; p = 0.0002), but there were more advanced tumors in these groups, as demonstrated by a lower Karnowsky index, higher Ca 19-9 plasmatic level, greater tumor size, more advanced stage in the AJCC classification, and more tumor location in the uncinate process of the pancreas. Ten-year overall and disease-free survivals were significantly better in group A (19 and 20%) compared with group B (2.8 and 0%) and group C (0% and 0%). Multivariate analysis proved vascular resection and metastatic nodal status as being independent predictive factors of disease-free survival.

CONCLUSIONS

Vascular resection combined to pancreatoduodenectomy for pancreatic cancer increases local resectability without increasing mortality and morbidity rates but does not improve patients' disease cure rate.

In vitro and in vivo anticancer activity of a novel nano-sized formulation based on self-assembling polymers against pancreatic cancer

PURPOSE

To evaluate the in vitro and in vivo pancreatic anticancer activity of a nano-sized formulation based on novel polyallylamine grafted with 5% mole cholesteryl pendant groups (CH(5)-PAA).

METHODS

Insoluble novel anticancer drug, Bisnaphthalimidopropyldiaaminooctane (BNIPDaoct), was loaded into CH(5)-PAA polymeric self-assemblies by probe sonication. Hydrodynamic diameters and polydispersity index measurements were determined by photon correlation spectroscopy. The in vitro cytotoxicity evaluation of the formulation was carried out by the sulforhodamine B dye assay with human pancreatic adenocarcinoma BxPC-3 cells, while for the in vivo study, Xenograff mice were used. In vitro apoptotic cell death from the drug formulation was confirmed by flow cytometric analysis.

RESULTS

The aqueous polymer-drug formulation had a mean hydrodynamic size of 183 nm. The drug aqueous solubility was increased from negligible concentration to 0.3 mg mL(-1). CH(5)-PAA polymer alone did not exhibit cytotoxicity, but the new polymer-drug formulation showed potent in vitro and in vivo anticancer activity. The mode of cell death in the in vitro study was confirmed to be apoptotic. The in vivo results revealed that the CH(5)-PAA alone did not have any anti-proliferative effect, but the CH(5)-PAA-drug formulation exhibited similar tumour reduction efficacy as the commercial drug, gemcitabine.

CONCLUSIONS

The proposed formulation shows potential as pancreatic cancer therapeutics.

Current and emerging therapies for the treatment of pancreatic cancer

Pancreatic adenocarcinoma carries a dismal prognosis and remains a significant cause of cancer morbidity and mortality. Most patients survive less than 1 year; chemotherapeutic options prolong life minimally. The best chance for long-term survival is complete resection, which offers a 3-year survival of only 15%. Most patients who do undergo resection will go on to die of their disease. Research in chemotherapy for metastatic disease has made only modest progress and the standard of care remains the purine analog gemcitabine. For resectable pancreatic cancer, presumed micrometastases provide the rationale for adjuvant chemotherapy and chemoradiation (CRT) to supplement surgical management. Numerous randomized control trials, none definitive, of adjuvant chemotherapy and CRT have been conducted and are summarized in this review, along with recent developments in how unresectable disease can be subcategorized according to the potential for eventual curative resection. This review will also emphasize palliative care and discuss some avenues of research that show early promise.

The role of radiotherapy in multimodal treatment of pancreatic carcinoma

Pancreatic ductal carcinoma is one of the most lethal malignancies, but in recent years a number of positive developments have occurred in the management of pancreatic carcinoma. This article aims to give an overview of the current knowledge regarding the role of radiotherapy in the treatment of pancreatic ductal adenocarcinoma (PDAC). The results of meta-analyses, phase III-studies, and phase II-studies using chemoradiotherapy and chemotherapy for resectable and non-resectable PDAC were reviewed. The use of radiotherapy is discussed in the neoadjuvant and adjuvant settings as well as in the locally advanced situation. Whenever possible, radiotherapy should be performed as simultaneous chemoradiotherapy. Patients with PDAC should be offered entry into clinical trials to identify optimal treatment results.