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Dias E Silva D, Chung V. Neoadjuvant treatment for pancreatic cancer: Controversies and advances. Cancer Treat Res Commun 2024; 39:100804. [PMID: 38508132 DOI: 10.1016/j.ctarc.2024.100804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/28/2024] [Accepted: 03/02/2024] [Indexed: 03/22/2024]
Abstract
Despite the advancements in the treatment of localized pancreatic cancer, several unresolved issues persist in clinical practice, especially in the neoadjuvant setting. These include determining the criteria for selecting patients for treatment, identifying the most effective chemotherapy regimens, understanding the role of radiotherapy, and accurately assessing how patients respond to treatment. Current strategies for assessing patients before surgery involve thoroughly evaluating their overall health status, analyzing tumor markers, and using advanced imaging techniques. However, existing methods for staging the disease still have limitations when it comes to accurately detecting metastatic cancer. The ongoing debate between performing surgery upfront or administering neoadjuvant therapy highlights the need for robust clinical evidence to guide treatment decisions effectively. This review analyzes the evidence regarding controversial topics in neoadjuvant pancreatic cancer treatment and discusses further research efforts to enhance patient outcomes. To improve the outcomes found with surgery alone, multimodal treatment with chemotherapy.
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Affiliation(s)
| | - Vincent Chung
- City of Hope, 1500 E. Duarte Road, Duarte, CA 91010, United States.
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2
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Iliesiu A, Toma RV, Ciongariu AM, Costea R, Zarnescu N, Bîlteanu L. A pancreatic adenocarcinoma mimicking hepatoid carcinoma of uncertain histogenesis: A case report and literature review. Oncol Lett 2023; 26:442. [PMID: 37720666 PMCID: PMC10502951 DOI: 10.3892/ol.2023.14029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 06/19/2023] [Indexed: 09/19/2023] Open
Abstract
In rare cases, metastatic adenocarcinomas of different origin may exhibit the features of hepatoid carcinoma (HC), a rare malignant epithelial tumor, most commonly occurring in the ovaries and stomach, as well as in the pancreas and biliary ducts. A case of a 72-year-old female patient who developed a highly aggressive, poorly differentiated pancreatic ductal adenocarcinoma with peritoneal carcinomatosis, demonstrating hepatoid differentiation upon conventional hematoxylin and eosin staining is reported in the present study. The patient presented with severe abdominal pain, and the radiological investigations performed revealed ovarian and hepatic tumor masses and peritoneal lesions, which were surgically removed. The gross examination of the peritoneum and omentum revealed multiple solid, firm, grey-white nodules, diffusely infiltrating the adipose tissue. The microscopic examination revealed a malignant epithelial proliferation, composed of polygonal cells with abundant eosinophilic cytoplasm and irregular, pleomorphic nuclei. Certain cells presented with intracytoplasmic mucus inclusions, raising suspicion of a HC with an uncertain histogenesis. Immunohistochemical staining was performed, and the tumor cells were found to be positive for cytokeratin (CK)7, CK18 and mucin 5AC, whereas negative staining for CK20, caudal-type homeobox transcription factor 2, α-fetoprotein, paired box gene 8, GATA-binding protein 3 and Wilms tumor 1 were documented. Thus, the diagnosis of metastatic pancreatic adenocarcinoma was established. The main aim of the present study was to provide further knowledge concerning poorly differentiated metastatic adenocarcinoma resembling HC, emphasizing the histopathological and immunohistochemical features of these malignant lesions and raising awareness of the diagnostic difficulties that may arise, as well as the importance of the use immunohistochemistry in differentiating carcinomas of uncertain histogenesis.
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Affiliation(s)
- Andreea Iliesiu
- Department of Pathology, University Emergency Hospital of Bucharest, Bucharest 014461, Romania
- Faculty of General Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 050474, Romania
| | - Radu-Valeriu Toma
- Faculty of General Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 050474, Romania
- Oncological Institute ‘Alexandru Trestioreanu’, Bucharest 022328, Romania
| | - Ana Maria Ciongariu
- Department of Pathology, University Emergency Hospital of Bucharest, Bucharest 014461, Romania
- Faculty of General Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 050474, Romania
| | - Radu Costea
- Faculty of General Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 050474, Romania
- Second Department of Surgery, University Emergency Hospital of Bucharest, Bucharest 050098, Romania
| | - Narcis Zarnescu
- Faculty of General Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 050474, Romania
- Second Department of Surgery, University Emergency Hospital of Bucharest, Bucharest 050098, Romania
| | - Liviu Bîlteanu
- Oncological Institute ‘Alexandru Trestioreanu’, Bucharest 022328, Romania
- Department of Preclinical Sciences, Faculty of Veterinary Medicine, University of Agronomic Sciences and Veterinary Medicine, Bucharest 050097, Romania
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3
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Ren W, Xourafas D, Ashley SW, Clancy TE. Prognostic Factors in Patients With Borderline Resectable Pancreatic Ductal Adenocarcinoma Undergoing Resection. Am Surg 2022; 88:1172-1180. [PMID: 33522271 DOI: 10.1177/0003134821991962] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Neoadjuvant treatment (NT) has become standard in the management of borderline resectable pancreatic cancer (BR-PDAC), improving prognosis. The primary mechanism for this improvement remains unclear. METHODS Clinicopathological data of patients with BR-PDAC who underwent resection between January 2008 and December 2018 at a single institution were retrospectively reviewed. Univariable and multivariate analyses were used to compare survival between patients who received NT vs. those who underwent upfront resection (UR). RESULTS A total of 138 patients were included, 64 underwent UR and 74 NT. Neoadjuvant treatment resulted in higher margin-negative (R0) resection rate (68.9%) than UR (43.8%, P = .005). Neoadjuvant treatment was associated with improved overall survival (OS, P = .009) and progression-free survival (PFS, P = .027). R0 resection was also associated with improved OS (P < .001) and PFS (P < .001). On multivariable analysis, when adjusting for clinically relevant variables without considering R status, NT was an independent predictor for improved OS (P = .046) and PFS (P = .040). When additionally accounting for margin status, R0 was an independent predictor for improved OS (P < .001) and PFS (P < .001), while NT was not. Subgroup analysis, stratified by margin status, revealed that NT was not an independent predictor for OS or PFS for either subgroup. DISCUSSION Neoadjuvant treatment is associated with improved OS and PFS in patients with BR-PDAC; however, this effect is outweighed by margin status. These results suggest that the primary benefit of NT was dependent on facilitating R0 resection. Upfront resection might remain a valid treatment option if R0 resection could be accurately predicted.
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Affiliation(s)
- Weizheng Ren
- Faculty of Hepato-Pancreato-Biliary Surgery, First Center, 104607Chinese PLA General Hospital, Beijing, China
- Department of Surgery, 1861Brigham and Women's Hospital, Boston, MA, USA
- 1811Harvard Medical School, Boston, MA, USA
| | - Dimitrios Xourafas
- Department of Surgery, 1861Brigham and Women's Hospital, Boston, MA, USA
- 1811Harvard Medical School, Boston, MA, USA
| | - Stanley W Ashley
- Department of Surgery, 1861Brigham and Women's Hospital, Boston, MA, USA
- 1811Harvard Medical School, Boston, MA, USA
| | - Thomas E Clancy
- Department of Surgery, 1861Brigham and Women's Hospital, Boston, MA, USA
- 1811Harvard Medical School, Boston, MA, USA
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4
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Lee JE, Kang YW, Jung KH, Son MK, Shin SM, Kim JS, Kim SJ, Fang Z, Yan HH, Park JH, Yoon YC, Han B, Cheon MJ, Woo MG, Seo MS, Lim JH, Kim YS, Hong SS. Intracellular KRAS-specific antibody enhances the anti-tumor efficacy of gemcitabine in pancreatic cancer by inducing endosomal escape. Cancer Lett 2021; 507:97-111. [PMID: 33744388 DOI: 10.1016/j.canlet.2021.03.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/16/2021] [Accepted: 03/11/2021] [Indexed: 02/07/2023]
Abstract
KRAS mutation is associated with the progression and growth of pancreatic cancer and contributes to chemo-resistance, which poses a significant clinical challenge in pancreatic cancer. Here, we developed a RT22-ep59 antibody (Ab) that directly targets the intracellularly activated GTP-bound form of oncogenic KRAS mutants after it is internalized into cytosol by endocytosis through tumor-associated receptor of extracellular epithelial cell adhesion molecule (EpCAM) and investigated its synergistic anticancer effects in the presence of gemcitabine in pancreatic cancer. We first observed that RT22-ep59 specifically recognized tumor-associated EpCAM and reached the cytosol by endosomal escape. In addition, the anticancer effect of RT22-ep59 was observed in the high-EpCAM-expressing pancreatic cancer cells and gemcitabine-resistant pancreatic cancer cells, but it had little effect on the low-EpCAM-expressing pancreatic cancer cells. Additionally, co-treatment with RT22-ep59 and gemcitabine synergistically inhibited cell viability, migration, and invasion in 3D-cultures and exhibited synergistic anticancer activity by inhibiting the RAF/ERK or PI3K/AKT pathways in cells with high-EpCAM expression. In an orthotopic mouse model, combined administration of RT22-ep59 and gemcitabine significantly inhibited tumor growth. Furthermore, the co-treatment suppressed cancer metastasis by blocking EMT signaling in vitro and in vivo. Our results demonstrated that RT22-ep59 synergistically increased the antitumor activity of gemcitabine by inhibiting RAS signaling by specifically targeting KRAS. This indicates that co-treatment with RT22-ep59 and gemcitabine might be considered a potential therapeutic strategy for pancreatic cancer patients harboring KRAS mutation.
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Affiliation(s)
- Ji Eun Lee
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Yeo Wool Kang
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Kyung Hee Jung
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Mi Kwon Son
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Seung-Min Shin
- Department of Molecular Science and Technology, Ajou University, Suwon, 16499, Republic of Korea
| | - Ji-Sun Kim
- Department of Molecular Science and Technology, Ajou University, Suwon, 16499, Republic of Korea
| | - Soo Jung Kim
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Zhenghuan Fang
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Hong Hua Yan
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Jung Hee Park
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Young-Chan Yoon
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Boreum Han
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Min Ji Cheon
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Min Gyu Woo
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Myung Sung Seo
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Joo Han Lim
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea
| | - Yong-Sung Kim
- Department of Molecular Science and Technology, Ajou University, Suwon, 16499, Republic of Korea.
| | - Soon-Sun Hong
- Department of Medicine, College of Medicine and Program in Biomedical Science & Engineering, Inha University, 3-ga, Sinheung-dong, Jung-gu, Incheon, 400-712, Republic of Korea.
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5
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Okano K, Suzuki Y. Influence of bile contamination for patients who undergo pancreaticoduodenectomy after biliary drainage. World J Gastroenterol 2019; 25:6847-6856. [PMID: 31885425 PMCID: PMC6931003 DOI: 10.3748/wjg.v25.i47.6847] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/07/2019] [Accepted: 12/13/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The influence of bile contamination on the infectious complications of patients undergoing pancreaticoduodenectomy (PD) has not been thoroughly evaluated.
AIM To evaluate the effect of preoperative biliary drainage and bile contamination on the outcomes of patients who undergo PD.
METHODS The database of 4101 patients who underwent PD was reviewed. Preoperative biliary drainage was performed in 1964 patients (47.9%), and bile contamination was confirmed in 606 patients (14.8%).
RESULTS The incidence of postoperative infectious complications was 37.9% in patients with preoperative biliary drainage and 42.4% in patients with biliary contamination, respectively. Patients with extrahepatic bile duct carcinoma, ampulla of Vater carcinoma, and pancreatic carcinoma had a high frequency of preoperative biliary drainage (82.9%, 54.6%, and 50.8%) and bile contamination (34.3%, 26.2%, and 20.2%). Bile contamination was associated with postoperative pancreatic fistula (POPF) Grade B/C, wound infection, and catheter infection. A multivariate logistic regression analysis revealed that biliary contamination (odds ratio 1.33, P = 0.027) was the independent risk factor for POPF Grade B/C. The three most commonly cultured microorganisms from bile (Enterococcus, Klebsiella, and Enterobacter) were identical to those isolated from organ spaces.
CONCLUSION In patients undergoing PD, bile contamination is related to postoperative infectious complication including POPF Grade B/C. The management of biliary contamination should be standardised for patients who require preoperative biliary drainage for PD, as the main microorganisms are identical in both organ spaces and bile.
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Affiliation(s)
- Keiichi Okano
- Departments of Gastroenterological Surgery, Kagawa University, Kita-gun, Kagawa 761-0793, Japan
| | - Yasuyuki Suzuki
- Departments of Gastroenterological Surgery, Kagawa University, Kita-gun, Kagawa 761-0793, Japan
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6
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Pandé R, Roberts KJ. Determining Optimal Routes to Surgery for Borderline Resectable Venous Pancreatic Cancer-Where Is the Least Harm and Most Benefit? Front Oncol 2019; 9:1060. [PMID: 31681596 PMCID: PMC6811510 DOI: 10.3389/fonc.2019.01060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/30/2019] [Indexed: 11/13/2022] Open
Abstract
Surgery among patients with borderline resectable pancreatic cancer (BRPC) and venous disease has emerged as a viable strategy to achieve curative treatment. By definition, these patients are at increased risk of a positive resection margin, however, controversy exists with regards to necessity of radical surgery and optimum pathways with no consensus on definitive treatment. A surgery first approach is possible though outcomes vary but patients can have an efficient pathway to surgery, particularly if biliary drainage is avoided which limits overall complications. Neoadjuvant therapy (NAT) is emerging as a widely used strategy to improve oncological outcomes, including resection margin status. However, some patients progress on NAT whilst others suffer major complications whilst elderly patients are unlikely to be offered effective NAT limiting the widespread applicability of this therapy. In this article an overview of the entire pathway is presented along with assimilation of current best evidence to determine optimal routes to surgery for BRPC with venous involvement.
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Affiliation(s)
- Rupaly Pandé
- Department of HPB Surgery and Liver Transplant, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Keith J Roberts
- Department of HPB Surgery and Liver Transplant, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Department of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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7
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Long-term outcome following neoadjuvant therapy for resectable and borderline resectable pancreatic cancer compared to upfront surgery: a meta-analysis of comparative studies by intention-to-treat analysis. Surg Today 2019; 49:295-299. [PMID: 30877550 DOI: 10.1007/s00595-019-01786-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/17/2019] [Indexed: 02/07/2023]
Abstract
The aim of the study was to evaluate the effect of neoadjuvant therapy on long-term survival in patients with resectable and borderline resectable pancreatic cancer. A meta-analysis was conducted using the reported randomized, controlled trials and retrospective studies using an intention-to-treat analysis to compare upfront surgery and neoadjuvant therapy in resectable or borderline resectable pancreatic cancer patients. Six comparative studies consisting of two randomized, controlled trials and four retrospective studies were included. The overall pooled hazard ratio was 0.66 (95% confidence interval: 0.50-0.87, P = 0.003), indicating that patients in the neoadjuvant group had better long-term survival than those in the upfront surgery group. However, considerable inter-study heterogeneity was observed (I2 = 62%). This meta-analysis focusing on comparative studies analyzed by intention-to-treat analysis showed that neoadjuvant therapy for resectable and borderline resectable pancreatic cancer tends to improve patients' long-term outcomes. However, the evidence level remains too low for a firm conclusion. The well-designed, randomized, controlled trials now ongoing will provide the definite evidence needed in the future.
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8
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Piątek M, Kuśnierz K, Bieńkowski M, Pęksa R, Kowalczyk M, Nawrocki S. Primarily resectable pancreatic adenocarcinoma - to operate or to refer the patient to an oncologist? Crit Rev Oncol Hematol 2019; 135:95-102. [PMID: 30819452 DOI: 10.1016/j.critrevonc.2019.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/12/2019] [Accepted: 01/21/2019] [Indexed: 12/13/2022] Open
Abstract
The aim of this work is to investigate the optimal therapeutic sequence of resectable pancreatic cancer - primary surgery with adjuvant therapy or neoadjuvant followed by resection. Application of the neoadjuvant approach in routine treatment of pancreatic cancer is rapidly growing every year, despite the lack of final results from randomized trials. Recent advancements in the adjuvant therapy, due to the more effective chemotherapy regimens, favor the upfront surgery strategy. On the other hand, theoretical background and metaanalyses favor the neoadjuvant strategy. Currently, primary resection with adjuvant chemotherapy remains the standard approach in resectable pancreatic cancer, but the first recommendations considering the neoadjuvant approach as an option seem to arise among the scientific societies with a global impact. Preliminary results of Prodige 24 study and PREOPANC-1 trial demonstrates that both options are worth further evaluation in clinical trials. Their results should soon provide more answers to this important clinical questions.
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Affiliation(s)
- Michał Piątek
- Department of Oncology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Kuśnierz
- Department of Gastrointestinal Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Rafał Pęksa
- Department of Patomorphology, Medical University of Gdańsk, Poland
| | - Marek Kowalczyk
- Department of Radiotherapy, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Sergiusz Nawrocki
- Department of Radiotherapy, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
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9
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Nelson DW, Chang SC, Grunkemeier G, Dehal AN, Lee DY, Fischer TD, DiFronzo LA, O'Connor VV. Resectable Distal Pancreas Cancer: Time to Reconsider the Role of Upfront Surgery. Ann Surg Oncol 2018; 25:4012-4019. [PMID: 30229418 DOI: 10.1245/s10434-018-6765-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Indexed: 08/08/2024]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) is increasingly utilized to optimize survival in proximal pancreatic adenocarcinoma. However, few studies have explored the impact of NAC in distal pancreas cancer. METHODS Patients with resectable pancreatic adenocarcinoma of the body or tail treated with either upfront pancreatectomy or NAC followed by surgery were identified in the 2006-2014 National Cancer Database. Trends in utilization, predictors of use, and impact of NAC on overall survival were determined. RESULTS Of 1485 patients, 176 (11.9%) received NAC. Use of NAC increased from 9.3% in 2006 to 16.9% in 2013 [odds ratio 1.14; 95% confidence interval (CI) 1.05-1.24; p = 0.001]. NAC patients were younger, had higher clinical stage, and preoperative CA 19-9 levels (all p < 0.05). After adjustment for patient-, tumor-, and treatment-related factors, increased clinical stage was the greatest independent predictor of neoadjuvant approach (p < 0.001). On multivariable analysis, survival benefit from NAC did not reach threshold of significance (95% CI 0.66-1.04; p = 0.10) for the entire cohort. However, NAC was associated with a significant survival advantage in clinical stage III with a 51% decreased yearly risk of death (adjusted hazard ratio 0.49; 95% CI 0.25-0.98; p = 0.04). A trend towards improved survival with NAC was observed among stage IIA (p = 0.09) and IIB (p = 0.07) patients. CONCLUSIONS Neoadjuvant chemotherapy is associated with improved overall survival in Stage III distal pancreatic adenocarcinoma and shows promise in earlier stage disease. However, only a small percentage of patients receive NAC. Prospective evaluation of NAC in distal pancreatic adenocarcinoma is warranted based on these findings.
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Affiliation(s)
- Daniel W Nelson
- Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Shu-Ching Chang
- Department of Biostatistics, Medical Data Research Center, Providence St. Joseph Health, Portland, OR, USA
| | - Gary Grunkemeier
- Department of Biostatistics, Medical Data Research Center, Providence St. Joseph Health, Portland, OR, USA
| | - Ahmed N Dehal
- Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - David Y Lee
- Department of Surgery, TriHealth Cancer Institute, Cincinnati, OH, USA
| | - Trevan D Fischer
- Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - L Andrew DiFronzo
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Victoria V O'Connor
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA. victoria.v.o'
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10
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Bal M, Rane S, Talole S, Ramadwar M, Deodhar K, Patil P, Goel M, Shrikhande S. Tumour origin and R1 rates in pancreatic resections: towards consilience in pathology reporting. Virchows Arch 2018; 473:293-303. [PMID: 30091124 DOI: 10.1007/s00428-018-2429-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 07/26/2018] [Accepted: 07/29/2018] [Indexed: 12/17/2022]
Abstract
To evaluate differences in the R1 rates of ampullary (AC), pancreatic (PC), and distal bile duct (DBD) cancers in pancreatoduodenectomies (PD) using standardised pathology assessment. Data of PD (2010-2011) analysed in accordance with the Royal College of Pathologists (UK) protocol, were retrieved. Clinicopathologic features, including frequency, topography, and mode of margin involvement in AC (n = 87), PC (n = 18), and DBD (n = 5) cancers were evaluated. The R1 rate was 7%, 67%, and 20% in the AC, PC, and DBD cancers (p < 0.001). Within the PC cohort, R1 rate was heterogeneous (chemo-naïve, 77%; post-neoadjuvant, 40%). Commonest involved margins were as follows: posterior in overall PD (35%), AC (43%), overall PC (33%), and post-neoadjuvant PC (100%); superior mesenteric artery margin in chemo-naïve PC (38%) and common bile duct margin in DBD (100%) cancers. In AC, majority (66%) of R1 were signet ring cell type. Indirect margin involvement due to tumour within lymph node, perineural sheath or lymphovascular space was observed in 26% cases, and altered R1 rate in AC, PC, and DBD cohorts by 1%, 12%, and 0%, respectively. Although not statistically significant, patients with R1 had lower disease-free survival than those with R0 (mean, 25.4 months versus 44.4 months). Tumour origin impacts R1 data in PD necessitating its accurate classification by pathologists. Indirect involvement, histology, and neoadjuvant therapy influence the R1 rate, albeit in a minority of cases. Generating cogent R1 data based on standardised pathology reporting is the foremost need of the hour.
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Affiliation(s)
- Munita Bal
- Department of Pathology, Tata Memorial Centre, Mumbai, 400012, India.
| | - Swapnil Rane
- Department of Pathology, Tata Memorial Centre, Mumbai, 400012, India
| | - Sanjay Talole
- Department of Epidemiology and Statistics, Tata Memorial Centre, Mumbai, India
| | - Mukta Ramadwar
- Department of Pathology, Tata Memorial Centre, Mumbai, 400012, India
| | - Kedar Deodhar
- Department of Pathology, Tata Memorial Centre, Mumbai, 400012, India
| | - Prachi Patil
- Department of Digestive Diseases and Nutrition, Tata Memorial Centre, Mumbai, India
| | - Mahesh Goel
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
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11
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Gilbert JW, Wolpin B, Clancy T, Wang J, Mamon H, Shinagare AB, Jagannathan J, Rosenthal M. Borderline resectable pancreatic cancer: conceptual evolution and current approach to image-based classification. Ann Oncol 2018; 28:2067-2076. [PMID: 28407088 DOI: 10.1093/annonc/mdx180] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Diagnostic imaging plays a critical role in the initial diagnosis and therapeutic monitoring of pancreatic adenocarcinoma. Over the past decade, the concept of 'borderline resectable' pancreatic cancer has emerged to describe a distinct subset of patients existing along the spectrum from resectable to locally advanced disease for whom a microscopically margin-positive (R1) resection is considered relatively more likely, primarily due to the relationship of the primary tumor with surrounding vasculature. Materials and methods This review traces the conceptual evolution of borderline resectability from a radiological perspective, including the debates over the key imaging criteria that define the thresholds between resectable, borderline resectable, and locally advanced or metastatic disease. This review also addresses the data supporting neoadjuvant therapy in this population and discusses current imaging practices before and during treatment. Results A growing body of evidence suggests that the borderline resectable group of patients may particularly benefit from neoadjuvant therapy to increase the likelihood of an ultimately margin-negative (R0) resection. Unfortunately, anatomic and imaging criteria to define borderline resectability are not yet universally agreed upon, with several classification systems proposed in the literature and considerable variance in institution-by-institution practice. As a result of this lack of consensus, as well as overall small patient numbers and lack of established clinical trials dedicated to borderline resectable patients, accurate evidence-based diagnostic categorization and treatment selection for this subset of patients remains a significant challenge. Conclusions Clinicians and radiologists alike should be cognizant of evolving imaging criteria for borderline resectability given their profound implications for treatment strategy, follow-up recommendations, and prognosis.
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Affiliation(s)
- J W Gilbert
- Department of Imaging, Dana-Farber Cancer Institute.,Department of Radiology, Brigham and Women's Hospital.,Harvard Medical School
| | - B Wolpin
- Harvard Medical School.,Department of Medical Oncology, Dana-Farber Cancer Institute
| | - T Clancy
- Harvard Medical School.,Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital
| | - J Wang
- Harvard Medical School.,Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital.,Gastrointestinal Surgical Center, Dana-Farber/Brigham and Women's Cancer Center
| | - H Mamon
- Harvard Medical School.,Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, USA
| | - A B Shinagare
- Department of Imaging, Dana-Farber Cancer Institute.,Department of Radiology, Brigham and Women's Hospital.,Harvard Medical School
| | - J Jagannathan
- Department of Imaging, Dana-Farber Cancer Institute.,Department of Radiology, Brigham and Women's Hospital.,Harvard Medical School
| | - M Rosenthal
- Department of Imaging, Dana-Farber Cancer Institute.,Department of Radiology, Brigham and Women's Hospital.,Harvard Medical School
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12
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Decreased Skeletal Muscle Volume Is a Predictive Factor for Poorer Survival in Patients Undergoing Surgical Resection for Pancreatic Ductal Adenocarcinoma. J Gastrointest Surg 2018; 22:831-839. [PMID: 29392613 PMCID: PMC6057620 DOI: 10.1007/s11605-018-3695-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 01/15/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to investigate the impact of decreased skeletal muscle (SM) volume on survival outcomes in patients undergoing surgical resection for pancreatic ductal adenocarcinoma (PDAC). METHODS Between March 2000 and February 2015, 323 patients who underwent upfront surgical resection for PDAC were identified from the Mayo Clinic SPORE in Pancreatic Cancer. Body composition data, including SM area, subcutaneous adipose tissue area, and visceral adipose tissue area were calculated using an abdominal computed tomography (CT) image at the third lumbar spinal level. The body composition data were normalized by patients' height (e.g., SM index, cm2/m2) and analyzed as continuous variables. Clinicopathological findings and body composition data at initial diagnosis were evaluated for association with overall survival and recurrence-free survival. RESULTS Because the median SM index was significantly different between males vs. females (49.9 cm2/m2 [range, 32.0-70.3] vs. 39.4 cm2/m2 [range, 29.2-66.2], P < 0.001), it was standardized for each sex and used for further analyses. Parameters independently associated with a shorter overall survival were a larger tumor size (P = 0.007), a greater tumor extent (P = 0.037), a higher carbohydrate antigen 19-9 level (P < 0.001), and a smaller sex-standardized SM index (P = 0.011). Parameters independently associated with a shorter recurrence-free survival were female sex (P = 0.029), a larger tumor size (P < 0.001), a higher carbohydrate antigen 19-9 level (P = 0.001), and a smaller sex-standardized SM index (P = 0.007). CONCLUSIONS A smaller sex-standardized SM index is a predictive factor for shorter overall and recurrence-free survival in PDAC patients undergoing surgery.
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13
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Mokdad AA, Minter RM, Zhu H, Augustine MM, Porembka MR, Wang SC, Yopp AC, Mansour JC, Choti MA, Polanco PM. Neoadjuvant Therapy Followed by Resection Versus Upfront Resection for Resectable Pancreatic Cancer: A Propensity Score Matched Analysis. J Clin Oncol 2016; 35:515-522. [PMID: 27621388 DOI: 10.1200/jco.2016.68.5081] [Citation(s) in RCA: 280] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose To compare overall survival between patients who received neoadjuvant therapy (NAT) followed by resection and those who received upfront resection (UR)-as well as a subgroup of UR patients who also received adjuvant therapy-for early-stage resectable pancreatic adenocarcinoma. Patients and Methods Adult patients with resected, clinical stage I or II adenocarcinoma of the head of the pancreas were identified in the National Cancer Database from 2006 to 2012. Patients who underwent NAT followed by curative-intent resection were matched by propensity score with patients whose tumors were resected upfront. Overall survival was compared by using a Cox proportional hazards regression model. Early postoperative and oncologic outcomes were evaluated. Results We identified 15,237 patients with clinical stage I or II resected pancreatic head adenocarcinoma. From the NAT group, 2,005 patients (95%) were matched with 6,015 patients who underwent UR. The NAT group was associated with improved survival compared with UR (median survival, 26 months v 21 months, respectively; stratified log-rank P < .01; hazard ratio, 0.72; 95% CI, 0.68 to 0.78). Patients in the UR group had higher pathologic T stage (pT3 and T4: 86% v 73%; P < .01), higher positive lymph nodes (73% v 48%; P < .01), and higher positive resection margin (24% v 17%; P < .01). Compared with a subset of UR patients who received adjuvant therapy, NAT patients had a better survival (adjusted hazard ratio, 0.83; 95% CI, 0.73 to 0.89). Conclusion NAT followed by resection has a significant survival benefit compared with UR in early-stage, resected pancreatic head adenocarcinoma. These findings support the use of NAT, particularly as a patient selection tool, in the management of resectable pancreatic adenocarcinoma.
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Affiliation(s)
- Ali A Mokdad
- All authors: University of Texas Southwestern Medical Center, Dallas, TX
| | - Rebecca M Minter
- All authors: University of Texas Southwestern Medical Center, Dallas, TX
| | - Hong Zhu
- All authors: University of Texas Southwestern Medical Center, Dallas, TX
| | - Mathew M Augustine
- All authors: University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew R Porembka
- All authors: University of Texas Southwestern Medical Center, Dallas, TX
| | - Sam C Wang
- All authors: University of Texas Southwestern Medical Center, Dallas, TX
| | - Adam C Yopp
- All authors: University of Texas Southwestern Medical Center, Dallas, TX
| | - John C Mansour
- All authors: University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael A Choti
- All authors: University of Texas Southwestern Medical Center, Dallas, TX
| | - Patricio M Polanco
- All authors: University of Texas Southwestern Medical Center, Dallas, TX
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14
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Abstract
Despite decades of scientific and clinical research, pancreatic ductal adenocarcinoma (PDAC) remains a lethal malignancy. The clinical and pathologic features of PDAC, specifically the known environmental and genetic risk factors, are reviewed here with special emphasis on the hereditary pancreatic cancer (HPC) syndromes. For these latter conditions, strategies are described for their identification, for primary and secondary prevention in unaffected carriers, and for disease management in affected carriers. Nascent steps have been made toward personalized medicine based on the rational use of screening, tumor subtyping, and targeted therapies; these have been guided by growing knowledge of HPC syndromes in PDAC.
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Affiliation(s)
- Ashton A Connor
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Steven Gallinger
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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15
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The Clinical and Pathological Significance of Nectin-2 and DDX3 Expression in Pancreatic Ductal Adenocarcinomas. DISEASE MARKERS 2015; 2015:379568. [PMID: 26294807 PMCID: PMC4534609 DOI: 10.1155/2015/379568] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/17/2015] [Accepted: 06/04/2015] [Indexed: 12/30/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly malignant disease, but the genetic basis of PDAC is still unclear. In this study, Nectin-2 and DDX3 expression in 106 PDAC, 35 peritumoral tissues, 55 benign pancreatic lesions, and 13 normal pancreatic tissues were measured by immunohistochemical methods. Results showed that the percentage of positive Nectin-2 and DDX3 expression was significantly higher in PDAC tumors than in peritumoral tissues, benign pancreatic tissues, and normal pancreatic tissues (P < 0.01). The percentage of cases with positive Nectin-2 and DDX3 expression was significantly lower in PDAC patients without lymph node metastasis and invasion and having TNM stage I/II disease than in patients with lymph node metastasis, invasion, and TNM stage III/IV disease (P < 0.05 or P < 0.01). Positive DDX3 expression is associated with poor differentiation of PDAC. Kaplan-Meier survival analysis showed that positive Nectin-2 and DDX3 expression were significantly associated with survival in PDAC patients (P < 0.001). Cox multivariate analysis revealed that positive Nectin-2 and DDX3 expression were independent poor prognosis factors in PDAC patients. In conclusion, positive Nectin-2 and DDX3 expression are associated with the progression and poor prognosis in PDAC patients.
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