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Stoop TF, Theijse RT, Seelen LWF, Groot Koerkamp B, van Eijck CHJ, Wolfgang CL, van Tienhoven G, van Santvoort HC, Molenaar IQ, Wilmink JW, Del Chiaro M, Katz MHG, Hackert T, Besselink MG. Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer. Nat Rev Gastroenterol Hepatol 2024; 21:101-124. [PMID: 38036745 DOI: 10.1038/s41575-023-00856-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 12/02/2023]
Abstract
Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rutger T Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Christopher L Wolfgang
- Division of Surgical Oncology, Department of Surgery, New York University Medical Center, New York City, NY, USA
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Radiation Oncology, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands.
- Cancer Center Amsterdam, Amsterdam, Netherlands.
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Hiroshima Y, Kondo M, Sawada T, Hoshi S, Okubo R, Iizumi T, Numajiri H, Okumura T, Sakurai H. Analysis of the cost-effectiveness of proton beam therapy for unresectable pancreatic cancer in Japan. Cancer Med 2023; 12:20450-20458. [PMID: 37795771 PMCID: PMC10652344 DOI: 10.1002/cam4.6611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/28/2023] [Accepted: 09/22/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Proton beam therapy (PBT) has recently been included in Japan's social health insurance benefits package. This study aimed to determine the cost-effectiveness of PBT for unresectable, locally advanced pancreatic cancer (LAPC) as a replacement for conventional photon radiotherapy (RT). METHODS We estimated the incremental cost-effectiveness ratio (ICER) of PBT as a replacement for three-dimensional conformal RT (3DCRT), a conventional photon RT, using clinical evidence in the literature and expense complemented by expert opinions. We used a decision tree and an economic and Markov model to illustrate the disease courses followed by LAPC patients. Effectiveness was estimated as quality-adjusted life years (QALY) using utility weights for the health state. Social insurance fees were calculated as the costs. The stability of the ICER against the assumptions made was appraised using sensitivity analyses. RESULTS The effectiveness of PBT and 3DCRT was 1.67610615 and 0.97181271 QALY, respectively. The ICER was estimated to be ¥5,376,915 (US$46,756) per QALY. According to the suggested threshold for anti-cancer therapy from the Japanese authority of ¥7,500,000 (US$65,217) per QALY gain, such a replacement would be considered cost-effective. The one-way and probabilistic sensitivity analyses demonstrated stability of the base-case ICER. CONCLUSION PBT, as a replacement for conventional photon radiotherapy, is cost-effective and justifiable as an efficient use of finite healthcare resources. Making it a standard treatment option and available to every patient in Japan is socially acceptable from the perspective of health economics.
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Affiliation(s)
- Yuichi Hiroshima
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
- QST hospital, National Institutes for Quantum and Radiological Sciences and TechnologyChibaChibaJapan
- Department of Radiation Oncology, Ibaraki Prefectural Central HospitalKasamaIbarakiJapan
| | - Masahide Kondo
- Department of Health Care Policy and Health Economics, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Takuya Sawada
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Shu‐ling Hoshi
- Department of Health Care Policy and Health Economics, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Reiko Okubo
- Department of Health Care Policy and Health Economics, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
- Department of Clinical Laboratory MedicineUniversity of Tsukuba HospitalTsukubaIbarakiJapan
- Department of Nephrology, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Takashi Iizumi
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Haruko Numajiri
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Toshiyuki Okumura
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
- Department of Radiation Oncology, Ibaraki Prefectural Central HospitalKasamaIbarakiJapan
| | - Hideyuki Sakurai
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
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Umezawa R, Mizuma M, Nakagawa K, Yamamoto T, Takahashi N, Suzuki Y, Kishida K, Omata S, Unno M, Jingu K. Clinical impact of multimodal treatment including chemoradiotherapy, conversion surgery and postoperative chemotherapy for borderline resectable and unresectable locally advanced pancreatic cancer without disease progression after gemcitabine plus nab-paclitaxel. Pancreatology 2023; 23:650-656. [PMID: 37453848 DOI: 10.1016/j.pan.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/31/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The purpose of this study was to investigate treatment outcomes of chemoradiotherapy (CRT) using S-1 with or without conversion surgery after gemcitabine plus nab-paclitaxel (GnP) for borderline resectable (BR) and unresectable locally advanced (UR-LA) pancreatic cancer. METHODS From 2016 to 2020, patients without disease progression after GnP for BR or UR-LA pancreatic cancer underwent CRT with S-1. If distant metastasis was not detected after CRT, conversion surgery and oral administration of S-1 as postoperative adjuvant chemotherapy for at least 6 months was performed. RESULTS Forty patients were included in the present study. The median number of cycles of GnP was 6. Surgery was performed after CRT in 25 patients. The median progression-free survival (PFS) and overall survival (OS) periods from the start of radiotherapy were 24.6 and 27.4 months, respectively. The OS periods from the start of radiotherapy in patients who underwent conversion surgery and those who did not undergo conversion surgery were 41.3 and 16.8 months, respectively. The PFS periods from the start of radiotherapy in patients who underwent surgery and those who did not undergo surgery were 28.3 and 8.6 months, respectively. Patients who were able to receive S-1 after conversion surgery for more than 6 months had better OS than those who were not (p = 0.039), although there was no significant difference of PFS (p = 0.365). CONCLUSIONS In BR/UR-LA pancreatic cancer without disease progression after GnP, multimodal treatment including CRT, conversion surgery and the scheduled postoperative chemotherapy may be effective.
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Affiliation(s)
- Rei Umezawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Masamichi Mizuma
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Nakagawa
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Suzuki
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keita Kishida
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - So Omata
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Elkhamisy SA, Valentini C, Lattermann A, Radhakrishna G, Künzel LA, Löck S, Troost EGC. Normo- or Hypo-Fractionated Photon or Proton Radiotherapy in the Management of Locally Advanced Unresectable Pancreatic Cancer: A Systematic Review. Cancers (Basel) 2023; 15:3771. [PMID: 37568587 PMCID: PMC10416887 DOI: 10.3390/cancers15153771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/13/2023] Open
Abstract
LAPC is associated with a poor prognosis and requires a multimodal treatment approach. However, the role of radiation therapy in LAPC treatment remains controversial. This systematic review aimed to explore the role of proton and photon therapy, with varying radiation techniques and fractionation, in treatment outcomes and their respective toxicity profiles. METHODS Clinical studies published from 2012 to 2022 were systematically reviewed using PubMed, MEDLINE (via PubMed) and Cochrane databases. Different radiotherapy-related data were extracted and analyzed. RESULTS A total of 31 studies matched the inclusion criteria. Acute toxicity was less remarkable in stereotactic body radiotherapy (SBRT) compared to conventionally fractionated radiotherapy (CFRT), while in proton beam therapy (PBT) grade 3 or higher acute toxicity was observed more commonly with doses of 67.5 Gy (RBE) or higher. Late toxicity was not reported in most studies; therefore, comparison between groups was not possible. The range of median overall survival (OS) for the CFRT and SBRT groups was 9.3-22.9 months and 8.5-20 months, respectively. For the PBT group, the range of median OS was 18.4-22.3 months. CONCLUSION CFRT and SBRT showed comparable survival outcomes with a more favorable acute toxicity profile for SBRT. PBT is a promising new treatment modality; however, additional clinical studies are needed to support its efficacy and safety.
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Affiliation(s)
- Sally A. Elkhamisy
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Chiara Valentini
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Annika Lattermann
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | | | - Luise A. Künzel
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden—Rossendorf (HZDR), 01307 Dresden, Germany
| | - Steffen Löck
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden—Rossendorf (HZDR), 01307 Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Esther G. C. Troost
- OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, 01307 Dresden, Germany; (S.A.E.); (A.L.)
- The Christie Hospital NHS Foundation Trust, Manchester M20 4BX, UK;
- National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and Helmholtz Association/Helmholtz-Zentrum Dresden—Rossendorf (HZDR), 01307 Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology-OncoRay, 01328 Dresden, Germany
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Ejlsmark MW, Schytte T, Bernchou U, Bahij R, Weber B, Mortensen MB, Pfeiffer P. Radiotherapy for Locally Advanced Pancreatic Adenocarcinoma-A Critical Review of Randomised Trials. Curr Oncol 2023; 30:6820-6837. [PMID: 37504359 PMCID: PMC10378124 DOI: 10.3390/curroncol30070499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
Pancreatic cancer is rising as one of the leading causes of cancer-related death worldwide. Patients often present with advanced disease, limiting curative treatment options and therefore making management of the disease difficult. Systemic chemotherapy has been an established part of the standard treatment in patients with both locally advanced and metastatic pancreatic cancer. In contrast, the use of radiotherapy has no clear defined role in the treatment of these patients. With the evolving imaging and radiation techniques, radiation could become a plausible intervention. In this review, we give an overview over the available data regarding radiotherapy, chemoradiation, and stereotactic body radiation therapy. We performed a systematic search of Embase and the PubMed database, focusing on studies involving locally advanced pancreatic cancer (or non-resectable pancreatic cancer) and radiotherapy without any limitation for the time of publication. We included randomised controlled trials involving patients with locally advanced pancreatic cancer, including radiotherapy, chemoradiation, or stereotactic body radiation therapy. The included articles represented mainly small patient groups and had a high heterogeneity regarding radiation delivery and modality. This review presents conflicting results concerning the addition of radiation and modality in the treatment regimen. Further research is needed to improve outcomes and define the role of radiation therapy in pancreatic cancer.
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Affiliation(s)
- Mathilde Weisz Ejlsmark
- Department of Oncology, Odense University Hospital, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Uffe Bernchou
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Laboratory of Radiation Physics, Odense University Hospital, 5000 Odense, Denmark
| | - Rana Bahij
- Department of Oncology, Odense University Hospital, 5000 Odense, Denmark
| | - Britta Weber
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark
- Danish Centre of Particle Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Michael Bau Mortensen
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Department of Surgery, Odense University Hospital, 5000 Odense, Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
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Shimomura O, Endo M, Makishima H, Yamada T, Hashimoto S, Numajiri H, Miyazaki Y, Doi M, Furuya K, Takahashi K, Moriwaki T, Hasegawa N, Yamamoto Y, Niisato Y, Kobayashi M, Mizumoto M, Nakai K, Saito T, Hoshiai S, Saida T, Mathis BJ, Mori K, Nakajima T, Tsuchiya K, Sakurai H, Oda T. Triple modal treatment comprising with proton beam radiation, hyperthermia, and gemcitabine/nab-paclitaxel for locally advanced pancreatic cancer: a phase I/II study protocol (TT-LAP trial). BMC Cancer 2023; 23:624. [PMID: 37403011 DOI: 10.1186/s12885-023-11110-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 06/26/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Locally advanced pancreatic ductal adenocarcinoma (PDAC), accounting for about 30% of PDAC patients, is difficult to cure by radical resection or systemic chemotherapy alone. A multidisciplinary strategy is required and our TT-LAP trial aims to evaluate whether triple-modal treatment with proton beam therapy (PBT), hyperthermia, and gemcitabine plus nab-paclitaxel is a safe and synergistically effective treatment for patients with locally advanced PDAC. METHODS This trial is an interventional, open-label, non-randomized, single-center, single-arm phase I/II clinical trial organized and sponsored by the University of Tsukuba. Eligible patients who are diagnosed with locally advanced pancreatic cancer, including both borderline resectable (BR) and unresectable locally advanced (UR-LA) patients, and selected according to the inclusion and exclusion criteria will receive triple-modal treatment consisting of chemotherapy, hyperthermia, and proton beam radiation. Treatment induction will include 2 cycles of chemotherapy (gemcitabine plus nab-paclitaxel), proton beam therapy, and 6 total sessions of hyperthermia therapy. The initial 5 patients will move to phase II after adverse events are verified by a monitoring committee and safety is ensured. The primary endpoint is 2-year survival rate while secondary endpoints include adverse event rate, treatment completion rate, response rate, progression-free survival, overall survival, resection rate, pathologic response rate, and R0 (no pathologic cancer remnants) rate. The target sample size is set at 30 cases. DISCUSSION The TT-LAP trial is the first to evaluate the safety and effectiveness (phases1/2) of triple-modal treatment comprised of proton beam therapy, hyperthermia, and gemcitabine/nab-paclitaxel for locally advanced pancreatic cancer. ETHICS AND DISSEMINATION This protocol was approved by the Tsukuba University Clinical Research Review Board (reference number TCRB22-007). Results will be analyzed after study recruitment and follow-up are completed. Results will be presented at international meetings of interest in pancreatic cancer plus gastrointestinal, hepatobiliary, and pancreatic surgeries and published in peer-reviewed journals. TRIAL REGISTRATION Japan Registry of Clinical Trials, jRCTs031220160. Registered 24 th June 2022, https://jrct.niph.go.jp/en-latest-detail/jRCTs031220160 .
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Affiliation(s)
- Osamu Shimomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, 305-8575, Japan
| | - Masato Endo
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan
| | | | - Takeshi Yamada
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan
| | - Shinji Hashimoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, 305-8575, Japan
| | - Haruko Numajiri
- Department of Radiation oncology, University of Tsukuba, Ibaraki, Japan
| | - Yoshihiro Miyazaki
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, 305-8575, Japan
| | - Manami Doi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, 305-8575, Japan
| | - Kinji Furuya
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, 305-8575, Japan
| | - Kazuhiro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, 305-8575, Japan
| | | | - Naoyuki Hasegawa
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan
| | | | - Yusuke Niisato
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan
| | - Mariko Kobayashi
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan
| | - Masashi Mizumoto
- Department of Radiation oncology, University of Tsukuba, Ibaraki, Japan
| | - Kei Nakai
- Department of Radiation oncology, University of Tsukuba, Ibaraki, Japan
| | - Takashi Saito
- Department of Radiation oncology, University of Tsukuba, Ibaraki, Japan
| | - Sodai Hoshiai
- Department of Radiology, University of Tsukuba, Ibaraki, Japan
| | - Tsukasa Saida
- Department of Radiology, University of Tsukuba, Ibaraki, Japan
| | - Bryan J Mathis
- International Medical Center, University of Tsukuba Hospital, Ibaraki, Japan
| | - Kensaku Mori
- Department of Radiology, University of Tsukuba, Ibaraki, Japan
| | | | - Kiichiro Tsuchiya
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan
| | - Hideyuki Sakurai
- Department of Radiation oncology, University of Tsukuba, Ibaraki, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Ibaraki, 305-8575, Japan.
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7
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Mizuno N, Ioka T, Ogawa G, Nakamura S, Hiraoka N, Ito Y, Katayama H, Takada R, Kobayashi S, Ikeda M, Miwa H, Okano N, Kuramochi H, Sekimoto M, Okusaka T, Ozaka M, Todaka A, Gotoh K, Tobimatsu K, Yamaguchi H, Nakagohri T, Kajiura S, Sudo K, Okamura K, Shimizu S, Shirakawa H, Kato N, Sano K, Iwai T, Fujimori N, Ueno M, Ishii H, Furuse J. Effect of systemic inflammatory response on induction chemotherapy followed by chemoradiotherapy for locally advanced pancreatic cancer: an exploratory subgroup analysis on systemic inflammatory response in JCOG1106. Jpn J Clin Oncol 2023:7185478. [PMID: 37248668 PMCID: PMC10390851 DOI: 10.1093/jjco/hyad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/03/2023] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVE JCOG1106, a randomized phase II trial conducted to compare chemoradiotherapy (S-1 concurrent radiotherapy) with (Arm B) or without (Arm A) induction chemotherapy using gemcitabine in patients with locally advanced pancreatic cancer, showed a more favorable long-term survival in Arm A. This study was aimed at exploring whether some subgroups classified by the systemic inflammatory response might derive greater benefit from either treatment. METHODS All subjects eligible for JCOG1106 were included in this analysis (n = 51/49 in Arm A/B). This exploratory subgroup analysis was performed by Cox regression analysis to investigate the impact of the systemic inflammatory response, as assessed based on the serum C-reactive protein, serum albumin (albumin), Glasgow Prognostic Score and derived neutrophil-lymphocyte ratio, at the baseline on overall survival. P values <0.1 for the interaction were regarded as denoting significant association. RESULTS Glasgow prognostic score showed significant treatment interactions for overall survival. Hazard ratios of Arm B to Arm A were 1.35 (95% confidence interval, 0.82-2.23) in the Glasgow Prognostic Score 0 (C-reactive protein ≤10 mg/L and albumin ≥35 g/L) (n = 44/34 in Arm A/B) and 0.59 (95% confidence interval, 0.24-1.50) in the Glasgow Prognostic Score 1/2 (C-reactive protein >10 mg/L and/or albumin <35 g/L) (n = 7/15) (P-interaction = 0.06). C-reactive protein alone and albumin alone also showed significant treatment interactions for overall survival. CONCLUSIONS Survival benefits of induction chemotherapy in chemoradiotherapy for locally advanced pancreatic cancer were observed in patients with elevated Glasgow Prognostic Score, high C-reactive protein and low albumin. These results suggest that systemic inflammatory response might be considered to apply induction chemotherapy preceding chemoradiotherapy.
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Affiliation(s)
- Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tatsuya Ioka
- Oncology Center, Yamaguchi University Hospital, Yamaguchi, Japan
- Department of Cancer Survey and Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Gakuto Ogawa
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Satoaki Nakamura
- Division of Radiation Oncology, Kansai Medical University Hospital, Osaka, Japan
| | - Nobuyoshi Hiraoka
- Division of Pathology and Clinical Laboratories, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, Showa Universtity School of Medicine, Tokyo, Japan
| | - Hiroshi Katayama
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Ryoji Takada
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Satoshi Kobayashi
- Department of Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Haruo Miwa
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Naohiro Okano
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Mitaka, Japan
| | - Hidekazu Kuramochi
- Department of Chemotherapy and Palliative Care, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Masato Ozaka
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiko Todaka
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, Sunto-gun, Japan
| | - Kunihito Gotoh
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Kazutoshi Tobimatsu
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Hironori Yamaguchi
- Department of Clinical Oncology, Jichi Medical University, Shimotsuke, Japan
| | - Toshio Nakagohri
- Department of Gastroenterological Surgery, School of Medicine Tokai University, Isehara, Japan
| | - Shinya Kajiura
- Department of Clinical oncology, Toyama University Hospital, Toyama, Japan
| | - Kentaro Sudo
- Department of Gastroenterology, Chiba Cancer Center, Chiba, Japan
| | - Keiya Okamura
- Department of Bilio-Pancreatology, Sapporo Kosei General Hospital, Sapporo, Japan
| | - Satoshi Shimizu
- Department of Gastroenterology, Saitama Cancer Center, Kita-adachi-gun, Japan
| | - Hirofumi Shirakawa
- Department of Hepatobiliary-Pancreatic Surgery, Tochigi Cancer Center, Utsunomiya, Japan
| | - Naoya Kato
- Department of Gastroenterology, Chiba University School of Medicine, Chiba, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Makoto Ueno
- Department of Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
| | - Hiroshi Ishii
- Clinical Research Center, Chiba Cancer Center, Chiba, Japan
| | - Junji Furuse
- Department of Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Mitaka, Japan
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8
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Clinical Implications of FDG-PET in Pancreatic Ductal Adenocarcinoma Patients Treated with Neoadjuvant Therapy. J Gastrointest Surg 2023; 27:337-346. [PMID: 36652179 DOI: 10.1007/s11605-023-05591-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/07/2023] [Indexed: 01/19/2023]
Abstract
PURPOSE To evaluate the clinical significance of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with pancreatic ductal adenocarcinoma who underwent neoadjuvant therapy. METHODS Among 285 consecutive patients who underwent pancreatic resection for pancreatic ductal adenocarcinoma between 2015 and 2021, 86 who underwent preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography after completion of neoadjuvant treatment were reviewed. Among preoperative factors, including post-treatment maximum standardized uptake value, predictors of early recurrence and poor prognosis were identified using multivariate analysis for decision making in surgery. RESULTS Nineteen (22%) patients with pancreatic ductal adenocarcinoma demonstrated high maximum standardized uptake (≥ 4.5). High post-treatment maximum standardized uptake (≥ 4.5) predicted early recurrence within 6 months after surgery and correlated with shorter recurrence-free survival. Elevated post-treatment CA19-9 level (> 37 U/ml) and maximum standardized uptake ≥ 4.5 were independent prognostic factors. Post-treatment, a high maximum standardized uptake value indicated a poorer prognosis than a low maximum standardized uptake value in both patients with elevated CA19-9 and normal CA19-9 levels. The median overall survival in patients with elevated post-treatment CA19-9 and high maximum standardized uptake was only 17 months; 67% experienced early recurrence. Dynamic changes in maximum standardized uptake during neoadjuvant therapy were correlated with pathological response to neoadjuvant therapy, but not with radiological response or change in CA19-9 level. CONCLUSIONS Post-treatment assessment using maximum standardized uptake value is useful for stratifying patients with pancreatic ductal adenocarcinoma who will benefit from surgery. Instead of subsequent curative resection, additional neoadjuvant therapy should be considered in patients with a persistently high maximum standardized uptake value.
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9
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Umezawa R, Nakagawa K, Mizuma M, Katsuta Y, Tanaka S, Kadoya N, Suzuki Y, Takeda K, Takahashi N, Yamamoto T, Unno M, Jingu K. Comparison of acute gastrointestinal toxicities between 3-dimensional conformal radiotherapy and intensity-modulated radiotherapy including prophylactic regions in chemoradiotherapy with S-1 for pancreatic cancer-importance of dose volume histogram parameters in the stomach as the predictive factors. JOURNAL OF RADIATION RESEARCH 2022; 63:856-865. [PMID: 35993332 PMCID: PMC9726699 DOI: 10.1093/jrr/rrac049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/28/2022] [Indexed: 06/15/2023]
Abstract
The purpose of this study was to compare acute gastrointestinal (GI) toxicities in patients who underwent 3-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT) in chemoradiotherapy (CRT) with S-1 including prophylactic regions for pancreatic cancer. We also investigated the predictive factor of acute GI toxicities in dose volume histogram (DVH) parameters. Patients who received CRT with S-1 for pancreatic cancer between January 2014 and March 2021 were included. Radiotherapy (RT) with a total dose of 50-54 Gy was delivered. We examined the differences in the frequencies of acute GI toxicity of grade 2 or higher and DVH parameters of the stomach (ST) and duodenum (DU) between the 3DCRT group and the IMRT group. The RT-related predictive factors of acute GI toxicities were investigated by univariate and multivariate analyses. There were 25 patients in the 3DCRT group and 31 patients in the IMRT group. The frequencies of acute GI toxicity of G2 or higher were 36% in the 3DCRT group and 9.7% in the IMRT group (p = 0.035). ST V50 was the most predictive factor (p = 0.001), and the incidences of acute GI toxicity of G2 or higher in ST V50 ≥ 4.1 cc and < 4.1cc were 43.7% and 7.7%, respectively. ST V40 was also a significant predictive factor of acute GI toxicity (p = 0.002). IMRT could reduce acute GI toxicities in CRT with S-1 including prophylactic regions for pancreatic cancer. Acute GI toxicities may be affected by moderate to high doses to the ST.
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Affiliation(s)
- Rei Umezawa
- Corresponding author. Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1, Seiryou-machi, Aobaku, Sendai 980-8574, Japan. Tel: +81-22-717-7312; Fax: +81-22-717-7316; E-mail:
| | - Kei Nakagawa
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masamichi Mizuma
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiyuki Katsuta
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shohei Tanaka
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyuki Kadoya
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Suzuki
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuya Takeda
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
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10
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Efficacy of chemotherapy for patients with metastatic or recurrent pancreatic adenosquamous carcinoma: A multicenter retrospective analysis. Pancreatology 2022; 22:1159-1166. [PMID: 36150984 DOI: 10.1016/j.pan.2022.09.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 08/22/2022] [Accepted: 09/05/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Pancreatic adenosquamous carcinoma (PASC) is a rare variant of pancreatic ductal adenocarcinoma (PDAC). The usual treatment for metastatic or recurrent PASC is systemic chemotherapy in accordance with the PDAC treatment strategy. This study aimed to investigate the efficacy of chemotherapy, especially the benefit of recent combination therapies, in patients with metastatic or recurrent PASC. METHODS We conducted a multicenter retrospective analysis of 116 patients with metastatic or recurrent PASC treated with first-line chemotherapy between April 2001 and December 2017 at 24 Japanese institutions. RESULTS Combination chemotherapies included gemcitabine + nab-paclitaxel (GnP, n = 28), fluorouracil/leucovorin + irinotecan + oxaliplatin (FFX, n = 10), gemcitabine + S-1 (GS, n = 10), and others (n = 9). Monotherapies included gemcitabine (n = 51) and S-1 (n = 8). The median overall survival (OS) was 6.5, 7.3, and 4.3 months for the whole cohort, the combination therapy group, and the monotherapy group, respectively. Multivariate analysis indicated that combination therapy showed a better trend in OS than monotherapy (hazard ratio = 0.68; 95% confidence interval, 0.38-1.20). GnP or FFX were selected in 58.7% of patients after FFX was approved in Japan, and revealed a median OS, median progression-free survival, and objective response rate of 7.3 months, 2.8 months, and 26.9% in GnP and 7.2 months, 2.3 months, and 20.0% in FFX respectively. CONCLUSIONS This study suggests that combination therapy may be more effective than monotherapy. GnP and FFX showed similar and clinically meaningful efficacy for patients with metastatic or recurrent PASC.
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11
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Kucuk A, Topkan E, Selek U, Haksoyler V, Mertsoylu H, Besen AA, Pehlivan B. High Measures of Pre-Chemoradiotherapy Platelet-to-Albumin Ratio Indicates Poor Prognosis in Locally Advanced Pancreatic Cancer Patients. Ther Clin Risk Manag 2022; 18:421-428. [PMID: 35444422 PMCID: PMC9015102 DOI: 10.2147/tcrm.s359553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/03/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose In a lack of similar research, we meant to retrospectively investigate the prognostic significance of pre-chemoradiotherapy (C-CRT) platelet-to-albumin ratio (PAR) on the survival results of locally advanced unresectable pancreatic adenocarcinoma (LAPC) patients. Patients and Methods The present analysis included 139 LAPC patients who received C-CRT in total. The utility of pre-C-CRT cutoff(s) reshaping survival data was explored using receiver operating characteristic (ROC) curve analysis. The primary and secondary objectives were the associations between PAR levels and overall survival (OS) and progression-free survival (PFS) outcomes. Results At a median follow-up of 15.7 months (95% CI: 11.6–19.8), the overall cohort’s median and 5-year OS rates were 14.4 months (95% CI: 11.8–17) and 14.7%, respectively, while the corresponding PFS rates were 7.8 months (95% CI: 6.5–9.1) and 11.2%. Because the ROC curve analysis found 4.9 as the optimal PAR cutoff for both OS and PFS [area under the curve (AUC): 75.4%; sensitivity: 72.4%; specificity: 70.3%], we divided the patients into two PAR cohorts: PAR<4.9 (N=60) and PAR≥4.9 (N=79). Comparative analysis per PAR group exhibited significantly worse OS (11.2 vs 18.6 months, and 9.8% vs 20.9% at 5 years, P=0.003) and DFS (7 vs 14.3 months, and 7.6% vs 16.2% at 5 years, P=0.001) with PAR≥4.9 versus PAR<4.9, respectively. In multivariate analysis, the N0 nodal status, CA 19–9≤90 U/mL, and PAR<4.9 were found to be independent predictors of improved OS and PFS. Conclusion The pre-C-CRT high PAR (≥4.9) robustly and independently prognosticated significantly worse OS and PFS results in inoperable LAPC patients who underwent definitive C-CRT.
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Affiliation(s)
- Ahmet Kucuk
- Clinic of Radiation Oncology, Mersin Education and Research Hospital, Mersin, Turkey
| | - Erkan Topkan
- Department of Radiation Oncology, Baskent University Medical Faculty, Adana, Turkey
- Correspondence: Erkan Topkan, Department of Radiation Oncology, Baskent University Medical Faculty, Adana, Turkey, Tel +90-533-7381069, Fax +90-322-3444452, Email
| | - Ugur Selek
- Department of Radiation Oncology, Koc University School of Medicine, Istanbul, Turkey
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Huseyin Mertsoylu
- Department of Medical Oncology, Baskent University Medical Faculty, Adana, Turkey
| | - Ali Ayberk Besen
- Department of Medical Oncology, Baskent University Medical Faculty, Adana, Turkey
| | - Berrin Pehlivan
- Department of Radiation Oncology, Bahcesehir University, Istanbul, Turkey
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12
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Su YY, Chiu YF, Li CP, Yang SH, Lin J, Lin SJ, Chang PY, Chiang NJ, Shan YS, Ch'ang HJ, Chen LT. A phase II randomised trial of induction chemotherapy followed by concurrent chemoradiotherapy in locally advanced pancreatic cancer: the Taiwan Cooperative Oncology Group T2212 study. Br J Cancer 2021; 126:1018-1026. [PMID: 34921230 DOI: 10.1038/s41416-021-01649-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/01/2021] [Accepted: 11/22/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The objective of this study was to evaluate the efficacy and safety of induction chemotherapy (ICT), GOFL (gemcitabine, oxaliplatin plus fluorouracil (5-FU)/leucovorin) versus modified FOLFIRINOX (irinotecan, oxaliplatin plus 5-FU/leucovorin), followed by concurrent chemoradiotherapy (CCRT) in locally advanced pancreatic adenocarcinoma (LAPC). METHODS Chemo-naive patients with measurable LAPC were eligible and randomly assigned to receive biweekly ICT with either mFOLFIRINOX or GOFL for 3 months. Patients without systemic progression would have 5-FU- or gemcitabine-based CCRT (5040 cGy/28 fractions) and were then subjected to surgery or continuation of chemotherapy until treatment failure. The primary endpoint was 9-month progression-free survival (PFS) rate. RESULTS Between July 2013 and January 2019, 55 patients were enrolled. After ICT, 21 (77.8%) of 27 patients who received mFOLFIRINOX and 17 (60.7%) of 28 patients who received GOFL completed CCRT. Of them, one and five had per-protocol R0/R1 resection. On intent-to-treat analysis, the 9-month PFS rate, median PFS and overall survival in mFOLFIRINOX and GOFL arms were 30.5% versus 35.9%, 6.6 (95% confidence interval: 5.9-12.5) versus 7.6 months (3.9-12.3) and 19.6 (13.4-22.9) versus 17.9 months (13.4-23.9), respectively. Grade 3-4 neutropenia and diarrhoea during induction mFOLFIRINOX and GOFL were 37.0% versus 21.4% and 14.8% versus 3.6%, respectively. CONCLUSION Induction GOFL and mFOLFIRINOX followed by CCRT provided similar clinical outcomes in LAPC patients. CLINICALTRIAL. GOV IDENTIFIER NCT01867892.
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Affiliation(s)
- Yung-Yeh Su
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan.,Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yen-Feng Chiu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Chung-Pin Li
- Division of Clinical Skills Training, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan
| | - Shih-Hung Yang
- Department of Oncology, National Taiwan University Hospital and Graduate Institute of Oncology, National Taiwan University, College of Medicine, Taipei, Taiwan
| | - Johnson Lin
- Department of Hematology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shyh-Jer Lin
- Department of Hematology, Veteran General Hospital, Kaohsiung, Taiwan
| | - Ping-Ying Chang
- Division of Hematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Nai-Jung Chiang
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan.,Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yan-Shen Shan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Hui-Ju Ch'ang
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan. .,Department of Radiation Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Taipei Cancer Center, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.
| | - Li-Tzong Chen
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan. .,Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
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13
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The Survival Benefit of Chemoradiotherapy following Induction Chemotherapy with Gemcitabine Plus Nab-Paclitaxel for Unresectable Locally Advanced Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13184733. [PMID: 34572960 PMCID: PMC8470784 DOI: 10.3390/cancers13184733] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/14/2021] [Accepted: 09/20/2021] [Indexed: 12/27/2022] Open
Abstract
Simple Summary An optimal therapeutic strategy for unresectable locally advanced pancreatic cancer (UR-LAPC) has not been established. The aim of this retrospective study was to evaluate the therapeutic efficacy, progression-free survival (PFS), and overall survival (OS) of patients with UR-LAPC who underwent gemcitabine plus nab-paclitaxel (GnP) as first-line chemotherapy followed by chemoradiotherapy (CRT) compared to chemotherapy alone (CTx) at our department in a Japanese cancer referral center between February 2015 and July 2018. CRT resulted in significantly better PFS and OS than CTx. In the multivariate analyses, CRT following induction chemotherapy was identified as an independent prognostic factor for OS. In summary, patients with UR-LAPC experienced favorable treatment outcomes after receiving GnP as the first-line chemotherapy, especially when receiving additional CRT after tailored courses of induction chemotherapy. Thus, this treatment strategy represents a promising treatment option for selected patients with UR-LAPC. Abstract An optimal therapeutic strategy for unresectable locally advanced pancreatic cancer (UR-LAPC) has not been established. This study investigated the therapeutic efficacy of chemoradiotherapy (CRT) following induction chemotherapy with gemcitabine plus nab-paclitaxel (GnP) (CRT group) compared with systemic chemotherapy alone (CTx group) in patients with UR-LAPC. This was a retrospective study of 63 consecutive patients with UR-LAPC treated at our department in a Japanese cancer referral center between February 2015 and July 2018. We excluded patients who underwent other regimens and those enrolled in another prospective study. The CRT group (n = 25) exhibited significantly better progression-free survival (PFS) and overall survival (OS) than the CTx group (n = 20, PFS 17.9 vs. 7.6 months, p = 0.044; OS 29.2 vs. 17.4 months, p < 0.001). In the multivariate analyses, CRT following induction chemotherapy was identified as an independent prognostic factor for OS. Seven (15.6%) patients underwent conversion surgery, all of whom were in the CRT group. The R0 resection rate was 85.7% (6/7). In summary, patients with UR-LAPC experienced favorable treatment outcomes after receiving GnP as the first-line chemotherapy, especially when receiving additional CRT. Thus, this treatment strategy represents a promising treatment option for selected patients with UR-LAPC.
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14
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Topkan E, Selek U, Pehlivan B, Kucuk A, Haksoyler V, Kilic Durankus N, Sezen D, Bolukbasi Y. The Prognostic Significance of Novel Pancreas Cancer Prognostic Index in Unresectable Locally Advanced Pancreas Cancers Treated with Definitive Concurrent Chemoradiotherapy. J Inflamm Res 2021; 14:4433-4444. [PMID: 34511977 PMCID: PMC8427684 DOI: 10.2147/jir.s329611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/18/2021] [Indexed: 12/22/2022] Open
Abstract
Purpose We evaluated the prognostic quality of the novel pancreas cancer prognostic index (PCPI), a combination of CA 19-9 and systemic inflammation response index (SIRI), on the outcomes of locally advanced pancreas adenocarcinoma (LAPAC) patients who received concurrent chemoradiotherapy (C-CRT). Methods This retrospective analysis covered 152 unresectable LAPAC patients treated from 2007 to 2019. Receiver operating characteristic (ROC) curve analysis was used to define ideal cutoff thresholds for the pretreatment CA 19-9 and SIRI measurements, individually. The associations between the PCPI groups and progression-free- (PFS) and overall survival (OS) comprised the respective primary and secondary endpoints. Results The ROC curve analysis distinguished the respective rounded optimal cutoffs at 91 U/m/L (< versus ≥90) and 1.8 (< versus ≥1.8) for CA 19-9 and SIRI, arranging the study cohort into two significantly different survival groups for each, with resultant four likely groups: Group-1: CA 19-9<90 U/m/L and SIRI<1.8, Group-2: CA 19-9<90 U/m/L but SIRI≥1.8, Group-3: CA 19-9≥90 U/m/L but SIRI<1.8, and Group-4: CA 19-9≥90 U/m/L and SIRI≥1.8. Since the PFS (P=0.79) and OS (P=0.86) estimates of the groups 2 and 3 were statistically indistinct, we merged them as one group and created the novel three-tiered PCPI: PCPI-1: CA 19-9<90 U/m/L and SIRI<1.8, PCPI-2: CA 19-9<90 U/m/L but SIRI≥1.8 or CA 19-9≥90 U/m/L but SIRI<1.8, and PCPI-3: CA 19-9≥90 U/m/L and SIRI≥1.8, respectively. Comparative analyses unveiled that the PCPI-1 and PCPI-3 groups had the respective best and worst PFS (17.0 versus 7.5 versus 4.4 months; P<0.001) and OS (26.1 versus 15.1 versus 7.4 months; P<0.001) outcomes, while the PCPI-2 group posed in between. The multivariate analysis outcomes confirmed the novel three tired PCPI’s independent prognostic significance on either of the PFS [HR: 5.38 (95% confidence interval (CI): 4.96-5.80); P<0.001)] and OS [HR: 5.67 (95% CI: 5.19-6.15); P<0.001] endpoints, separately. Conclusion The new PCPI introduced here can be used as an independent and reliable prognostic indicator to divide LAPAC patients into three subgroups with discrete survival results.
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Affiliation(s)
- Erkan Topkan
- Department of Radiation Oncology, Baskent University Medical Faculty, Adana, Turkey
| | - Ugur Selek
- Department of Radiation Oncology, Koc University Faculty of Medicine, Istanbul, Turkey.,Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Berrin Pehlivan
- Department of Radiation Oncology, Bahcesehir University, Istanbul, Turkey
| | - Ahmet Kucuk
- Radiation Oncology Clinics, Mersin City Hospital, Mersin, Turkey
| | | | | | - Duygu Sezen
- Department of Radiation Oncology, Koc University Faculty of Medicine, Istanbul, Turkey
| | - Yasemin Bolukbasi
- Department of Radiation Oncology, Koc University Faculty of Medicine, Istanbul, Turkey.,Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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15
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Tomasello G, Ghidini M, Ghidini A, Trevisan F, Celotti A, Russo A, Gambini D, Indini A, Rijavec E, Bareggi C, Galassi B, Petrelli F. Total neoadjuvant therapy for initially inoperable pancreatic cancer: A systematic review of phase 2-3 studies. Radiother Oncol 2021; 164:13-19. [PMID: 34509562 DOI: 10.1016/j.radonc.2021.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients with initially inoperable non-metastatic pancreatic cancer (PC) have a poor prognosis, often similar to those with metastatic disease. Neoadjuvant chemotherapy (CT) plus concomitant or sequential radiotherapy (RT) may cause tumor shrinkage and allow for radical surgery. We pooled data of studies in which patients with locally advanced (unresectable) or borderline resectable PC were treated with a course of induction (or consolidation) CT followed or preceded by neoadjuvant CTRT regimen. MATERIALS AND METHODS We searched articles, including phase 2 or 3 studies, published in English from 2010 up to December 2020 in PubMed, SCOPUS, the Cochrane Library, and EMBASE. The primary outcomes were the pooled radical and R0 resection rates, median PFS and OS of included patients (those included in the intent to treat analysis). RESULTS A total of 28 studies were finally considered eligible for inclusion in quantitative analysis for a total of 2446 patients with locally advanced/borderline resectable PC. Overall the pooled rate of resection was 29.7% (95%CI 26.7-32.8%). In patients who completed the CT + CTRT program, the overall resection rate was 31.8% (95% 28.4-35.4%). After exclusion of studies that included resectable PCs, the overall resection rate was 19.9% (95%CI 17.3-22.7%). In studies were all patients had unresectable PC (n = 20 studies), the resection rate was 12.1% (95%CI 10-14.5%). In two studies that enrolled all borderline resectable PCs the resection rate was 59.2% (95%CI 48.9-68.8%). The pooled R0 resection rate was 68.7% (95%CI 64.7-72.3%). The median pooled OS was 15.7 months (95%CI 14-17.2 months) and the median pooled PFS was 10.7 (95%CI 9.3-12.1 months). CONCLUSIONS Surgery is a treatment option in about one third of patients with initially inoperable PC, following total neoadjuvant therapy. In unresectable cases the resection rate was 12%. Median OS and PFS rates were comparable with historical data of advanced PCs. Optimal integration and sequence of chemo- and radiotherapy in unresectable PC must still be defined.
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Affiliation(s)
- Gianluca Tomasello
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Michele Ghidini
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Ghidini
- Medical Oncology Unit, Casa di Cura Igea, Milan, Italy; GISCAD (Gruppo Italiano Studio Carcinomi Apparato Digerente)
| | | | - Andrea Celotti
- General Surgery 2, ASST Bergamo Ovest, Ospedale di Treviglio, Italy
| | - Alessandro Russo
- General Surgery 2, ASST Bergamo Ovest, Ospedale di Treviglio, Italy
| | - Donatella Gambini
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Indini
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Erika Rijavec
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Bareggi
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Galassi
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fausto Petrelli
- Oncology Unit, ASST Bergamo Ovest, Ospedale di Treviglio, Italy; GISCAD (Gruppo Italiano Studio Carcinomi Apparato Digerente)
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16
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Kobayashi S, Ueno M, Ogawa G, Fukutomi A, Ikeda M, Okusaka T, Sato T, Ito Y, Kadota T, Ioka T, Sugimori K, Sata N, Nakamori S, Shimizu K, Mizuno N, Ishii H, Furuse J. Impact of Renal Function on S-1 + Radiotherapy for Locally Advanced Pancreatic Cancer: An Integrated Analysis of Data From 2 Clinical Trials. Pancreas 2021; 50:965-971. [PMID: 34629456 DOI: 10.1097/mpa.0000000000001879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES S-1 monotherapy with concurrent radiotherapy (RT) is a standard of care for patients with locally advanced pancreatic cancer (LAPC). Although renal dysfunction increases S-1 monotherapy toxicity, its effect in S-1 with concurrent RT remains unknown. We evaluated the effect of renal function on the safety of S-1 with RT for LAPC. METHODS We performed an integrated exploratory post hoc analysis of data from 2 prospective studies (JCOG1106 and LAPC-S1RT), where patients with LAPC received RT (50.4 Gy/28 fraction for 5.5 weeks) and concurrent S-1 (40 mg/m2 per dose, twice daily on the day of irradiation). We split the patients into high creatinine clearance (CCr; ≥80 mL/min) and low CCr (<80 mL/min) groups and compared the findings to determine treatment safety. RESULTS The high and low CCr groups showed a median of 97.5 (range, 80.0-194.6) and 64.4 (range, 50.0-78.3) mL/min, respectively. The low CCr group presented more adverse reactions (ARs) of grade 3 or higher and gastrointestinal ARs of grade 2 or higher than the high CCr group (30.8% vs 15.8% and 51.9% vs 36.8%). CONCLUSIONS The incidence of ARs associated with concurrent S-1 and RT increases in patients with low CCr; therefore, ARs should be duly considered in such patients.
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Affiliation(s)
- Satoshi Kobayashi
- From the Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama City
| | - Makoto Ueno
- From the Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama City
| | - Gakuto Ogawa
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital, Tokyo
| | - Akira Fukutomi
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, Nagaizumi
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo
| | - Tosiya Sato
- Department of Biostatistics, Kyoto University School of Public Health, Kyoto City
| | - Yoshinori Ito
- Department of Radiation Oncology, Showa University School of Medicine, Shinagawa City
| | - Tomohiro Kadota
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital, Tokyo
| | - Tatsuya Ioka
- Department of Cancer Survey and Gastrointestinal Oncology, Osaka International Cancer Center, Osaka City
| | - Kazuya Sugimori
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama City
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Simono City
| | - Shoji Nakamori
- Department of Hepatobiliary and Pancreatic Surgery, Osaka National Hospital, Osaka City
| | - Kyoko Shimizu
- Department of Gastroenterology, Tokyo Women's Medical University Hospital, Tokyo
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya City
| | - Hiroshi Ishii
- Gastrointestinal Medical Oncology, Chiba Cancer Center, Chiba City
| | - Junji Furuse
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Mitaka City, Japan
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