Treatment of cancer of the exocrine pancreas

Pancreatic head cancer in patients with chronic pancreatitis

BACKGROUND

Chronic pancreatitis (CP) is a risk factor of pancreatic adenocarcinoma (PA). The discovery of a pancreatic head lesion in CP frequently leads to a pancreaticoduodenectomy (PD) which preceded by a multidisciplinary meeting (MM). The aim of this study was to evaluate the relevance between this indication of PD and the definitive pathological results.

METHODS

Between 2000 and 2010, all patients with CP who underwent PD for suspicion of PA without any histological proof were retrospectively analyzed. The operative decision has always been made at an MM. The definitive pathological finding was retrospectively confronted with the decision made at an MM, and patients were classified in two groups according to this concordance (group 1) or not (group 2). Clinical and biological parameters were analyzed, preoperative imaging were reread, and confronted to pathological findings in order to identify predictive factors of malignant degeneration.

RESULTS

During the study period, five of 18 (group 1) patients with CP had PD were histologically confirmed to have PA, and the other 13 (group 2) did not have PA. The median age was 52.5+/-8.2 years (gender ratio 3.5). The main symptoms were pain (94.4%) and weight loss (72.2%). There was no patient's death. Six (33.3%) patients had a major complication (Clavien-Dindo classification ≥ 3). There was no statistical difference in clinical and biological parameters between the two groups. The rereading of imaging data could not detect efficiently all patients with PA.

CONCLUSIONS

Our results confirmed the difficulty in detecting malignant transformation in patients with CP before surgery and therefore an elevated rate of unnecessary PD was found. A uniform imaging protocol is necessary to avoid PD as a less invasive treatment could be proposed.

Efficacy of the double-pigtail stent as a conservative treatment for grade B pancreatic fistula after pancreatoduodenectomy with pancreatogastric anastomosis

BACKGROUND

Despite improvements in surgical techniques and postoperative care, morbidity associated with pancreatoduodenectomy (PD) is still high. Grade B pancreatic fistula (PF) requires a specific combination of radiologically guided external drainage and medical support. This treatment is effective but requires prolonged hospitalization and maintenance of external drainage. The objective of this study was to evaluate the feasibility and efficacy of a double-pigtail stent (DPS) to treat grade B PF after PD with pancreatogastric anastomosis.

METHODS

Between January 2008 and October 2011, all patients who presented grade B PF after PD (n = 6) were included in the study. The PF was diagnosed according to the criteria of the International Study Group on Pancreatic Fistula. Endoscopic treatment was standardized with a DPS. The primary efficacy end point was the feasibility and efficacy of DPS placement. Secondary end points included data on the PF, the DPS placement procedure, and long-term outcome.

RESULTS

Endoscopic DPS placement was achieved in all patients with no complications. The median time to onset of PF after PD was 14 days. Closure of the external PF was obtained 7 days after the introduction of the DPS. The median time to external drain removal was 7 days after DPS placement, and the median time to oral refeeding was 7 days after DPS placement for all patients. The median time to DPS removal was 60 days. The median length of hospital stay after DPS placement was 10 days. During a median follow-up period of 21 months, there was no recurrence of PF after removal of the DPS.

CONCLUSION

Endoscopic treatment of grade B PF after PD appears to be effective and safe and is associated with shorter hospitalization.

[Significance of color Doppler ultrasonography in the assessment of pancreatic carcinoma vascular invasion]

BACKGROUND/AIM

It is highly appreciated to provide exact data on vascular invasion of pancreatic carcinoma relying as much as possible on non-invasive diagnostic procedures. Color Doppler ultrasonography has been proven as an efficient method for clinical staging of pancreatic carcinoma essential for therapeutic decisions. The aim of this study was to provide an analysis of the sensitivity and specificity for color Doppler ultrasonography in patients suffering from pancreatic carcinoma.

METHODS

We performed color Doppler ultrasonography examination in 43 patients with pancreatic carcinoma prior to the surgery. The findings of ultrasonography on neoplasm vascular invasion were correlated to the findings obtained during the subsequent surgical procedures. An estimation of neoplastic invasion of certain blood vessels including portal vein, celiac trunk, and superior mesenteric artery and vein is critical for decision making regarding surgical treatment. The patients with metastases of pancreatic carcinoma were excluded from the study.

RESULTS

Comparing color Doppler and the surgical findings we estimated the sensitivity for detection of neoplastic vascular invasion ranging from 79-93%, whereas the specificity range was from 83-93%.

CONCLUSION

Color Doppler ultrasonography is a sufficiently sensitive and specific method for evaluation of vascular invasion in pancreatic carcinoma patients. Since color Doppler ultrasonography is a non-invasive, radiation free, and inexpensive diagnostic tool, considering also the results of this and similar studies we could strongly recommend its use for an initial presurgical evaluation of vascular invasion in pancreatic carcinoma patients.

Endoscopic stenting versus surgical bypass in advanced malignant distal bile duct obstruction: cost-effectiveness analysis

OBJECTIVE

Palliative treatment of obstructive jaundice from advanced tumour of the distal bile duct is controversial. The aim of this study was to compare the clinical outcomes and costs between endoscopic stent insertion and surgery.

METHODS

The clinical data for 116 patients treated with either endoscopic plastic stenting (65 patients) or surgical bypass (51 patients) were reviewed and analysed.

RESULTS

No significant difference was found between the two groups in terms of the length of hospital stay, survival time, cost, effectiveness, and early complications. However, late complications were significantly more common in the stenting group (p = 0.007). Jaundice recurred in 15 stented patients at a median time of 3 months due to stent blockage, and one surgical patient had recurrent jaundice from anastomosis stricture. Late gastric outlet obstruction occurred in one of 36 surgical patients who did not undergo prophylactic gastroenterostomy and one of 65 stented patients developed this complication.

CONCLUSION

Both techniques are equally effective in biliary drainage, but stenting has a higher rate of recurrent jaundice. We recommend surgery for patients with low surgical risks and endoscopic stent in those with a short life expectancy or those unfit for surgery.

Monoclonal antibody 16D10 to the C-terminal domain of the feto-acinar pancreatic protein binds to membrane of human pancreatic tumoral SOJ-6 cells and inhibits the growth of tumor xenografts

Feto-acinar pancreatic protein (FAPP) characterized by mAbJ28 reactivity is a specific component associated with ontogenesis and behaves as an oncodevelopment-associated antigen. We attempted to determine whether pancreatic tumoral SOJ-6 cells are expressed at their surface FAPP antigens and to examine if specific antibodies directed against these FAPP epitopes could decrease the growth of pancreatic tumors in a mice model. For this purpose, we used specific antibodies against either the whole FAPP, the O-glycosylated C-terminal domain, or the N-terminal domain of the protein. Our results indicate that SOJ-6 cells expressed at their surface a 32-kDa peptide corresponding to the C-terminal domain of the FAPP. Furthermore, we show, by using endoproteinase Lys-C or geldanamycin, a drug able to impair the FAPP secretion, that this 32-kDa peptide expressed on the SOJ-6 cell surface comes from the degradation of the FAPP. Finally, an in vivo prospective study using a preventative tumor model in nude mice indicates that targeting this peptide by the use of mAb16D10 inhibits the growth of SOJ-6 xenografts. The specificity of mAb16D10 for pancreatic tumors and the possibility to obtain recombinant structures of mucin-like peptides recognized by mAb16D10 and mAbJ28 are promising tools in immunologic approaches to cure pancreatic cancers.

Relationship between ?Gal epitope expression and decrease of tumorigenicity in pancreatic adenocarcinoma model

The alphaGal epitope is a carbohydrate structure, Galalpha1,3Galbeta1,4GlcNAc-R, synthesized on glycoconjugates in many mammals by alpha1,3galactosyltransferase. Humans do not express this epitope and present in serum large amounts of naturally occuring antibodies, which recognize the alphaGal epitopes and participate in the hyperacute rejection of xenograft. Studies indicated that the fundamental mechanism of hyperacute rejection involving the alphaGal epitope expression can be used in cancer therapy. We have previously suggested that the alphaGal epitope expression by human pancreatic tumoral cells could decrease the tumorigenic behavior of these cells. To determine whether the expression of the alphaGal epitope can modify the tumorigenicity of pancreatic cancer cells, we used a Syrian golden hamster pancreatic adenocarcinoma experimental model. The expression of alphaGal epitopes in the Syrian golden hamster pancreatic cancer cell line HaP-T1 was obtained by selecting stable cell clones transfected with murine alpha1,3galactosyltransferase gene. The alphaGal epitope expression resulted in a delay in the tumoral development of HaP-T1 cells in vivo after allograft transplantation of Syrian golden hamsters (2.5-fold, P < 0.05) and of nude mice. This result is associated with an 100% increase in survival time of nude mice bearing tumors expressing the alphaGal epitope. Our results confirm that the cell surface expression of alphaGal epitope decreases the tumorigenic behavior of pancreatic cancer cells. This novel property may be useful for the development of cancer gene immunotherapy strategy.

A role for human MUC4 mucin gene, the ErbB2 ligand, as a target of TGF-beta in pancreatic carcinogenesis

MUC4: encodes a large transmembrane mucin that is overexpressed in pancreatic adenocarcinomas. The molecular mechanisms responsible for that altered pattern of expression are unknown. TGF-beta, a pleiotropic cytokine, regulates numerous genes involved in pancreatic carcinogenesis via activation of the Smads proteins and MUC4 promoter is rich in Smad-binding elements. Our aim was to study whether the regulation of MUC4 expression by TGF-beta in pancreatic cancer cells was strictly dependent on Smad4 activity. Three pancreatic cancer cell lines, CAPAN-1 (MUC4+/Smad4-), CAPAN-2 (MUC4+/Smad4+) and PANC-1 (MUC4-/Smad4+), were used. By RT-PCR, transfection assays and immunohistochemistry, we show that (i) both MUC4 mRNA and apomucin expression are upregulated by TGF-beta, (ii) Smad2 positively cooperates with Smad4 to activate the promoter, (iii) activation of Smad4 by exogenous TGF-beta induces Smad4 binding to the promoter, (iv) Smad7 and c-ski both inhibit activation by Smad4. When Smad4 is mutated and inactive, TGF-beta activates MUC4 expression via MAPK, PI3K and PKA signaling pathways. Absence of expression in PANC-1 cells is due to histone deacetylation. Altogether, these results indicate that upregulation of MUC4 by TGF-beta is restricted to well-differentiated pancreatic cancer cells, and point out a novel mechanism for TGF-beta as a key molecule in targeting MUC4 overexpression in pancreatic adenocarcinomas.

Decrease of human pancreatic cancer cell tumorigenicity by alpha1,3galactosyltransferase gene transfer

The enzyme alpha1,3galactosyltransferase synthesizes the alphaGal epitope, a carbohydrate structure (Galalpha1,3Galbeta1,4GlcNAc-R), on glycoconjugates in lower mammals. The enzyme is absent in humans but large amounts of natural antibodies that recognize alphaGal epitopes are present in human serum. It is likely that these antibodies contribute to the host defense and participate in the hyperacute rejection of xenograft. Previous studies indicated that the glycosyltransferase gene transfer into tumoral cells can modify the structure of glycoconjugates at the cell surface and, as a consequence, modulates the metastatic and tumorigenic behaviors of these cells. The aim of our study was to determine whether the expression of alphaGal epitope can modify the tumorigenicity of human pancreatic cancer cells. The expression of alphaGal epitopes in the human pancreatic cancer cell lines BxPC-3 and Panc-1 was obtained by selecting stable cell clones transfected with murine alpha1,3galactosyltransferase gene. The expression of the enzyme activity in BxPC-3 and Panc-1 cells resulted in the formation at the cell surface of alphaGal epitopes that are recognized by human anti-alphaGal antibodies. alphaGal epitope expression at the surface of pancreatic cancer cells was associated with the fixation of complement 1q to human anti-alphaGal antibodies. The alphaGal epitope expression also resulted in a delay in the tumoral development of BxPC-3 and Panc-1 cells in vivo after xenograft transplantation of nude mice. In addition to the impairment of the metastatic potential of murine tumor cell lines and the activation of immune response, our study provides evidence that the cell surface expression of alphaGal epitopes also modulates the tumorigenic behavior of human pancreatic cancer cells.

Metastatic pancreatic cancer: emerging strategies in chemotherapy and palliative care

This update is devoted to discussion of optimal supportive and palliative care of patients with pancreatic cancer. Approximately 33,000 new cases of pancreatic cancer are predicted for the U.S. in 2002. Because diagnosis and intervention occur late in the course of this disease, the vast majority of patients already have metastatic disease at the time of diagnosis. These tumors are relatively resistant to systemic chemotherapy, making pancreatic cancer the fourth leading cause of cancer-related death in the U.S. and the Western world. For these reasons, efforts at identifying and treating disease-related symptomatology are priorities. This update overviews symptom management, supportive care strategies, and both standard and emerging palliative chemotherapy options. The incorporation of molecularly targeted therapies into treatment of metastatic pancreatic cancer is reviewed as well. These strategies are of relevance to internists, gastroenterologists, oncologists, and other specialists who care for patients with pancreatic cancer.

Postoperative pancreatic exocrine function influences body weight maintenance after pylorus-preserving pancreatoduodenectomy

BACKGROUND

Most patients who undergo pylorus-preserving pancreatoduodenectomy (PPPD) are able to gain their weight postoperatively. However, sometimes patients experience a lack of weight gain even at long term after PPPD. The aim of this study was to examine factors influencing a body weight change after PPPD.

METHODS

In 34 Japanese patients with PPPD, 28 clinical parameters were assessed as possible factors affecting body weight maintenance at long term (1 year) after the operation by univariate and multivariate analyses.

RESULTS

Univariate analysis showed that long operation time (P = 0.02), extended retroperitoneal lymph node dissection (P = 0.0005), intraoperative radiotherapy (P = 0.02), adjuvant postoperative chemotherapy (P = 0.02), histopathological diagnosis of pancreatic cancer (P = 0.02), postoperative ulceration (P = 0.007), and insufficient postoperative pancreatic exocrine function (P = 0.002) were significantly related with the lack of weight gain at long term after PPPD. Multivariate analysis regarding the seven profound factors revealed that the insufficient postoperative pancreatic exocrine function significantly affected the lack of weight gain after PPPD. The use of ordinary amount of pancreatic exocrine enzymes did not influence the weight gain after PPPD (P = 0.23).

CONCLUSIONS

In patients refractory to an ordinary amount of medicine, a large dosage of enzymes may be necessary to gain weight after PPPD.

Quality of life after pylorus-preserving pancreatoduodenectomy

BACKGROUND

With increasing numbers of long-term survivors after pylorus-preserving pancreatoduodenectomy (PPPD), postoperative quality of life (QOL) has become a great concern. However, few reports are available on data of the postoperative changes in QOL after PPPD.

METHODS

A total of 20 patients were studied regarding QOL before and at short term (within 2 months), intermediate term (6 months), and long term (1 year) after PPPD, using a questionnaire. The questionnaire consisted of 13 physical and 10 psychosocial items. The medical records were also reviewed to evaluate objective nutritional status. Factors predicting delayed recovery of QOL were examined at intermediate term by univariate and multivariate analyses.

RESULTS

Overall and physical QOL scores returned to the preoperative level at intermediate term after PPPD, showing parallel changes with the objective nutritional status. However, the scores of psychosocial condition, which reflected the patient's mental health, remained low even at long term. QOL scores at intermediate term in patients with pancreatic carcinoma were significantly lower than those with other diseases. Univariate analysis showed that preoperative body weight loss, impaired preoperative pancreatic exocrine function, long operative time, intraoperative radiotherapy, pancreatic carcinoma, and postoperative diarrhea were factors predicting the delayed recovery of QOL. Multivariate analysis revealed that preoperative pancreatic exocrine function significantly affected the delayed recovery of QOL.

CONCLUSIONS

Preoperative supplement of pancreatic enzymes together with perioperative mental care would improve QOL at long term after PPPD.

Palliative strategies for locally advanced unresectable and metastatic pancreatic cancer

Technical improvement in perioperative morbidity and mortality with improved long-term survival associated with pancreaticoduodenectomy for patients with pancreatic carcinoma has clearly established a role for this operation when performed with curative intent. Most patients with pancreatic adenocarcinoma will not be candidates for surgical resection of their disease. These patients will experience significant symptoms potentially requiring surgical and nonsurgical palliative interventions to treat unrelieved cancer-associated pain, obstructive jaundice, or the development of GOO. The primary goal for palliative interventions should be to relieve symptoms with minimal morbidity and to maintain or improve the quality of life for patients with an expected limited survival.

Peritoneal colonization by human pancreatic cancer cells is inhibited by antisense FUT3 sequence

Several alpha(1,3/1,4) fucosyltransferases expressed in human pancreatic cancer cells can participate in the biosynthesis of cell surface sialyl-Lewis a and sialyl-Lewis x antigens that contribute to hematogenous metastatis. Previously, we observed a significant increase of the alpha(1,4) fucosyltransferase activity in tumoral pancreatic cell lines, suggesting that FUT3 could be involved in the sialyl-Lewis antigen expression. Therefore, we invalidated the expression of FUT3 by expressing FUT3 antisense sequence in the human pancreatic tumor BxPC-3 cell line, which expresses the alpha(1,4) fucosyltransferase activity and harbors the cell surface sialyl-Lewis antigens. The decrease of FUT3 transcript after transfection of antisense cDNA of FUT3 in these cells results in a substantial reduction of sialyl-Lewis antigen expression on cell surface. This decreased antigen expression was associated with an inhibition of adhesive properties to E-selectin and a decrease of metastatic power of FUT3 antisense-transfected BxPC-3 cells as tested in nude mice. Our study provides evidence that the expression level of FUT3 may regulate the expression of sialyl-Lewis a and sialyl-Lewis x surface antigens and consequently could play an important role in metastatic properties of human pancreatic cancer cells.

Peritoneal colonization by human pancreatic cancer cells is inhibited by antisense FUT3 sequence

Several alpha(1,3/1,4) fucosyltransferases expressed in human pancreatic cancer cells can participate in the biosynthesis of cell surface sialyl-Lewis a and sialyl-Lewis x antigens that contribute to hematogenous metastatis. Previously, we observed a significant increase of the alpha(1,4) fucosyltransferase activity in tumoral pancreatic cell lines, suggesting that FUT3 could be involved in the sialyl-Lewis antigen expression. Therefore, we invalidated the expression of FUT3 by expressing FUT3 antisense sequence in the human pancreatic tumor BxPC-3 cell line, which expresses the alpha(1,4) fucosyltransferase activity and harbors the cell surface sialyl-Lewis antigens. The decrease of FUT3 transcript after transfection of antisense cDNA of FUT3 in these cells results in a substantial reduction of sialyl-Lewis antigen expression on cell surface. This decreased antigen expression was associated with an inhibition of adhesive properties to E-selectin and a decrease of metastatic power of FUT3 antisense-transfected BxPC-3 cells as tested in nude mice. Our study provides evidence that the expression level of FUT3 may regulate the expression of sialyl-Lewis a and sialyl-Lewis x surface antigens and consequently could play an important role in metastatic properties of human pancreatic cancer cells.

Enhancement of metastatic properties of pancreatic cancer cells by MUC1 gene encoding an anti-adhesion molecule

MUC1 mucin expression has been shown to be associated clinicopathologically with metastasis and poor clinical outcome in a variety of tumors. To further investigate this finding experimentally, human pancreatic cancer S2-013 cells overexpressing MUC1 were used for spontaneous metastatic potential in nude mice. It was found that the number of lung metastases of MUC1 transfectants was significantly higher than that of control cells. To analyze the molecular mechanisms that underlie the increased metastatic activity, in vitro adhesion assays were performed. MUC1 mucin expression enhancedin vitro invasiveness and motility of S2-013 cells, and decreased the binding of S2-013 cells to type I collagen, Type IV collagen and laminin. Similar effects were not observed for cells expressing tandem repeat-deleted MUC1 cDNA. Adhesion properties were abolished by benzyl-alpha-GalNAc treatment, indicating that glycosylation of the extracellular domain of MUC1 was essential for these biological adhesive functions. Our data support the hypothesis that MUC1 expression contributes to the metastatic ability of pancreatic cancer cells.

Current status of and future prospects for the medical management of adenocarcinoma of the exocrine pancreas

Adenocarcinoma of the exocrine pancreas is one of the most refractory neoplasms to medical treatment. Although of marginal value, 5-fluorouracil (5-FU) alone or in combination with other agents or modalities has been the standard surgical adjuvant approach to localized unresectable tumor as well as the standard treatment for disseminated pancreatic cancer. Recently, a new chemotherapeutic agent, gemcitabine, has been shown to be somewhat more effective than 5-FU against metastatic pancreatic cancer. Treatment with gemcitabine usually results in a greater likelihood of objective response and better symptom control than treatment with 5-FU or drug combinations that include 5-FU. However, treatment with gemcitabine does not improve overall survival of patients with disseminated neoplasm. Newer promising agents such as 9-nitrocamptothecin have recently entered clinical trials, and novel modalities (e.g., gene therapy) are nearing full-scale clinical trial. There are reasons to believe that these and other new initiatives may soon significantly improve the medical management of adenocarcinoma of the exocrine pancreas.

Factors influencing survival after resection for ductal adenocarcinoma of the head of the pancreas

BACKGROUND AND OBJECTIVES

Recent reports have demonstrated improvement in the 5-year actuarial survival for patients with resected ductal adenocarcinoma. The purpose of this study is to determine the factors favoring long-term survival after pancreaticoduodenectomy.

METHODS

Between 1974 and 1995, 75 patients with pancreatic head carcinoma underwent pancreaticoduodenectomy in our department.

RESULTS

Overall postoperative mortality rate was 5. 3% and morbidity was 24%. Median survival following resection was 17 months. Estimated 1-, 2-, and 5-year survival rates were 68%, 46.7%, and 18.7%, respectively. Five-year survival was greater for node-negative than for node-positive patients (41.7% vs. 7.8%, P < 0. 001) and for smaller (<3 cm) than for larger tumors (33.3% vs. 8.8%, P < 0.006). The 5-year survival in patients with negative margins (n = 60) was 23.3%, whereas no patient with positive margins (n = 15) survived at 13 months (P < 0.001). Multivariate analysis, performed by the Cox proportional hazards model, indicated that margin status, lymph node metastasis, tumor size, and poor histological differentiation were independent predictors of poor survival.

CONCLUSIONS

Five-year survival for patients undergoing pancreaticoduodenectomy for ductal adenocarcinoma of the pancreas was 18.7%. Survival was greater in the group of patients with negative lymph nodes, tumor size <3 cm, and negative margin status.