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Elshami M, Wu VS, Stitzel HJ, Hue JJ, Loftus AW, Kyasaram RK, Shanahan J, Ammori JB, Hardacre JM, Ocuin LM. To Revise or Not Revise? Isolated Margin Positivity in Localized Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2024:10.1245/s10434-024-15616-y. [PMID: 38896228 DOI: 10.1245/s10434-024-15616-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: 04/04/2024] [Accepted: 05/26/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND The study determined the proportion of patients with pancreatic adenocarcinoma (PDAC) who had margin-positive disease and no other adverse pathologic findings (APF) using institutional and administrative datasets. METHODS Patients with clinical stage I or II PDAC in the National Cancer Database (NCDB 2010-2020) and those who underwent pancreatectomy at the authors' institution (2010-2021) were identified. Isolated margin positivity (IMP) was defined as a positive surgical margin with no APF (negative nodes, no lymphovascular/perineural invasion). RESULTS The study included 225 patients from the authors' institution and 23,598 patients from the NCDB. The margin-positive rates were 21.8% and 20.3%, and the IMP rates were 0.4% and 0.5%, respectively. In the institutional cohort, 68.4% of the patients had recurrence, and most of the patients (65.6%) had distant recurrences. The median recurrence-free survival (RFS) was 63.3 months for no APF, not reached for IMP, 14.8 months for negative margins & 1 APF, 20.3 months for positive margins & 2 APFs, and 12.9 months with all APF positive. The patients in the NCDB with IMP had a lower median OS than the patients with no APF (20.5 vs 390 months), but a higher median OS than those with margin positivity plus 1 APF (20.5 vs 18.0 months) or all those with APF positivity (20.5 vs 15.4 months). Based on institutional rates of IMP, any margin positivity, neck margin positivity (NMP), and no APF, the fraction of patients who might benefit from neck margin revision was 1 in 100,000, and those likely to benefit from any margin revision was 1 in 18,500. In the NCDB, those estimated to derive potential benefit from margin revision was 1 in 25,000. CONCLUSIONS Isolated margin positivity in resected PDAC is rare, and most patients experience distant recurrence. Revision of IMP appears unlikely to confer benefit to most patients.
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Affiliation(s)
- Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Victoria S Wu
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Henry J Stitzel
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jonathan J Hue
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alexander W Loftus
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Ravi K Kyasaram
- Department of Cancer Informatics, University Hospitals Cleveland Medical Center/Seidman Cancer Center, Cleveland, OH, USA
| | - John Shanahan
- Department of Cancer Informatics, University Hospitals Cleveland Medical Center/Seidman Cancer Center, Cleveland, OH, USA
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Pedrazzoli S. Currently Debated Topics on Surgical Treatment of Pancreatic Ductal Adenocarcinoma: A Narrative Review on Surgical Treatment of Borderline Resectable, Locally Advanced, and Synchronous or Metachronous Oligometastatic Tumor. J Clin Med 2023; 12:6461. [PMID: 37892599 PMCID: PMC10607532 DOI: 10.3390/jcm12206461] [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: 09/06/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Previously considered inoperable patients (borderline resectable, locally advanced, synchronous oligometastatic or metachronous pancreatic adenocarcinoma (PDAC)) are starting to become resectable thanks to advances in chemo/radiotherapy and the reduction in operative mortality. METHODS This narrative review presents a chosen literature selection, giving a picture of the current state of treatment of these patients. RESULTS Neoadjuvant therapy (NAT) is generally recognized as the treatment of choice before surgery. However, despite the increased efficacy, the best pathological response is still limited to 10.9-27.9% of patients. There are still limited data on the selection of possible NAT responders and how to diagnose non-responders early. Multidetector computed tomography has high sensitivity and low specificity in evaluating resectability after NAT, limiting the resection rate of resectable patients. Ca 19-9 and Positron emission tomography are giving promising results. The prediction of early recurrence after a radical resection of synchronous or metachronous metastatic PDAC, thus identifying patients with poor prognosis and saving them from a resection of little benefit, is still ongoing, although some promising data are available. CONCLUSION In conclusion, high-level evidence demonstrating the benefit of the surgical treatment of such patients is still lacking and should not be performed outside of high-volume centers with interdisciplinary teams of surgeons and oncologists.
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Ritter AR, Miller ED. Intraoperative Radiation Therapy for Gastrointestinal Malignancies. Surg Oncol Clin N Am 2023; 32:537-552. [PMID: 37182991 DOI: 10.1016/j.soc.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Despite improvements in definitive therapy, many patients with gastrointestinal malignancies experience local recurrences or have unresectable disease making subsequent management often challenging and morbid. Although higher doses of radiation may offer improved local control, the ability for dose escalation of external beam radiation therapy is often limited by adjacent radiosensitive structures. Intraoperative radiation therapy allows for additional radiotherapy to be delivered directly to the tumor or areas at highest risk for local recurrence while minimizing toxicity to adjacent structures, offering potentially improved outcomes for patients with unresectable disease or those with a high risk of local recurrence.
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Minimally Invasive Versus Open Radical Antegrade Modular Pancreatosplenectomy: A Meta-Analysis. World J Surg 2021; 46:235-245. [PMID: 34609574 DOI: 10.1007/s00268-021-06328-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Radical antegrade modular pancreatosplenectomy (RAMPS) was introduced to improve the tangential resection margin rates and N1 node clearance following resection of malignancies of the pancreatic body and tail. Owing to its technical complexity, minimally invasive RAMPS (MI-RAMPS) has only been reported by a few centers worldwide. We performed this meta-analysis to compare both short- and long-term outcomes between open RAMPS (O-RAMPS) and minimally invasive RAMPS (MI-RAMPS). METHODS A systematic search of the electronic databases PubMed, Medline (via PubMed), Cochrane Register of Controlled Trials (CENTRAL), EMBASE, Scopus and Web of Science was performed to identify eligible studies published in the English language regardless of study design. The outcomes of interest were operation time, estimated blood loss, transfusion rates, overall complications, Grade B/C post-operative pancreatic fistula (POPF) rates, post-pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), length of stay (LOS), R0 resection rates, lymph node (LN) yield and overall survival (OS). RESULTS Five non-randomized studies comprising of a total 229 patients (89 MI-RAMPS, 140 O-RAMPS) were included for analysis. Intra-operative blood loss was observed to be significantly reduced in MI-RAMPS as compared to O-RAMPS (MD -256.16, P < 0.001), while LN yield was higher in O-RAMPS as compared to MI-RAMPS (MD -2.73, P = 0.02). There were no statistically significant differences observed for the other perioperative, oncologic and survival outcomes. CONCLUSIONS This meta-analysis provides early evidence to suggest that MI-RAMPS may produce comparable short- and long-term outcomes to O-RAMPS, when undertaken by appropriately skilled surgeons in well-selected patients. Further large-scale prospective studies are required to corroborate these findings.
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Dhall D, Shi J, Allende DS, Jang KT, Basturk O, Adsay NV, Kim GE. Towards a More Standardized Approach to Pathologic Reporting of Pancreatoduodenectomy Specimens for Pancreatic Ductal Adenocarcinoma: Cross-continental and Cross-specialty Survey From the Pancreatobiliary Pathology Society Grossing Working Group. Am J Surg Pathol 2021; 45:1364-1373. [PMID: 33899790 PMCID: PMC8446290 DOI: 10.1097/pas.0000000000001723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In recent literature and international meetings held, it has become clear that there are significant differences regarding the definition of what constitutes as margins and how best to document the pathologic findings in pancreatic ductal adenocarcinoma. To capture the current practice, Pancreatobiliary Pathology Society (PBPS) Grossing Working Group conducted an international multispecialty survey encompassing 25 statements, regarding pathologic examination and reporting of pancreatic ductal adenocarcinoma, particularly in pancreatoduodenectomy specimens. The survey results highlighted several discordances; however, consensus/high concordance was reached for the following: (1) the pancreatic neck margin should be entirely submitted en face, and if tumor on the slide, then it is considered equivalent to R1; (2) uncinate margin should be submitted entirely and perpendicularly sectioned, and tumor distance from the uncinate margin should be reported; (3) all other surfaces (including vascular groove, posterior surface, and anterior surface) should be examined and documented; (4) carcinoma involving separately submitted celiac axis specimen should be staged as pT4. Although no consensus was achieved regarding what constitutes R1 versus R0, most participants agreed that ink on tumor or at and within 1 mm to the tumor is equivalent to R1 only in areas designated as a margin, not surface. In conclusion, this survey raises the awareness of the discordances and serves as a starting point towards further standardization of the pancreatoduodenectomy grossing and reporting protocols.
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Affiliation(s)
- Deepti Dhall
- Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jiaqi Shi
- Department of Pathology, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Daniela S Allende
- Department of Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kee-Taek Jang
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nazmi Volkan Adsay
- Department of Pathology, Koç University and American Hospital, Istanbul, Turkey
| | - Grace E. Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA
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Oshima M, Okano K, Suto H, Ando Y, Kamada H, Masaki T, Takahashi S, Shibata T, Suzuki Y. Changes and prognostic impact of inflammatory nutritional factors during neoadjuvant chemoradiotherapy for patients with resectable and borderline resectable pancreatic cancer. BMC Gastroenterol 2020; 20:423. [PMID: 33317455 PMCID: PMC7734830 DOI: 10.1186/s12876-020-01566-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/01/2020] [Indexed: 01/05/2023] Open
Abstract
Background Inflammatory nutritional factors, such as the neutrophil/lymphocyte ratio (NLR), Glasgow Prognostic Score (GPS), modified GPS (mGPS), and C-reactive protein/albumin (CRP/Alb) ratio, have prognostic values in many types of cancer. In this study, the prognostic values of inflammatory nutritional scores were evaluated in the patients with resectable or borderline resectable pancreatic ductal adenocarcinoma (PDAC) after neoadjuvant chemoradiotherapy (NACRT). Methods A total of 49 patients who underwent pancreatectomy after NACRT from September 2009 to May 2016 were enrolled. The NACRT consisted of hypofractionated external-beam radiotherapy (30 Gy in 10 fractions) with concurrent S-1 (60 mg/m2) delivered 5 days/week for 2 weeks before pancreatectomy. Inflammatory nutritional scores were determined before and after NACRT in this series. Results The median NLR increased after NACRT (from 2.067 to 3.302), with statistical difference (p < 0.001). In multivariate analysis, high pre-NACRT mGPS (2 or 1; p = 0.0478) and significant increase in CRP/Alb ratio after NACRT (≧ 0.077; p = 0.0036) were associated with shorter overall survival. All patients were divided into two groups according to the ΔCRP/Alb ratio after NACRT: the group with high ΔCRP/Alb ratio (≧ 0.077) and the group with low ΔCRP/Alb ratio (< 0.077). The group with high ΔCRP/Alb ratio after NACRT (n = 13) not only had higher post-NACRT CRP levels (p < 0.001) but also had lower post-NACRT Alb levels (p = 0.002). Patients in the group with high ΔCRP/Alb ratio lost more body weight during NACRT (p = 0.03). Conclusion In addition to pre-NACRT mGPS, ΔCRP/Alb after NACRT could provide prognostic value in the patients with PDAC treated by NACRT.
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Affiliation(s)
- Minoru Oshima
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Hironobu Suto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Yasuhisa Ando
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Hideki Kamada
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Tsutomu Masaki
- Departments of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Shigeo Takahashi
- Radiation Oncology, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Toru Shibata
- Radiation Oncology, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
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First report on the feasibility of a permanently implantable uni-directional planar low dose rate brachytherapy sheet for patients with resectable or borderline resectable pancreatic cancer. Brachytherapy 2020; 20:207-217. [PMID: 32978081 DOI: 10.1016/j.brachy.2020.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Margin negative resection in pancreatic cancer remains the only curative option but is challenging, especially with the retroperitoneal margin. Intraoperative radiation therapy (IORT) can improve rates of local control but requires specially designed facilities and equipment. This retrospective review describes initial results of a novel implantable mesh of uni-directional low dose rate (LDR) Pd-103 sources (sheet) used to deliver a focal margin-directed high-dose boost in patients with concern for close or positive margins. METHODS Eleven consecutive patients from a single institution with resectable or borderline resectable pancreatic cancer with concern for positive margins were selected for sheet placement and retrospectively reviewed. Procedural outcomes, including the time to implant the device and complications, and clinical outcomes, including survival and patterns of failure, are reported. A dosimetric comparison of the LDR sheet with hypothetical stereotactic body radiotherapy (SBRT) boost is reported. RESULTS One patient had a resectable disease, and 10 patients had a borderline resectable disease and underwent neoadjuvant treatment. Sheet placement added 15 min to procedural time with no procedural or sheet-related complications. At a median follow up of 13 months, 64% (n = 7) of patients are alive and 55% (n = 6) are disease-free. Compared to a hypothetical SBRT boost, the LDR sheet delivered a negligible dose to kidneys, liver, and spinal cord with a 50% reduction in max dose to the small bowel. CONCLUSION This is the first report of the use of an implantable uni-directional LDR brachytherapy sheet in patients with resected pancreatic cancer with concern for margin clearance, with no associated toxicity and favorable clinical outcomes.
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Simionato F, Zecchetto C, Merz V, Cavaliere A, Casalino S, Gaule M, D'Onofrio M, Malleo G, Landoni L, Esposito A, Marchegiani G, Casetti L, Tuveri M, Paiella S, Scopelliti F, Giardino A, Frigerio I, Regi P, Capelli P, Gobbo S, Gabbrielli A, Bernardoni L, Fedele V, Rossi I, Piazzola C, Giacomazzi S, Pasquato M, Gianfortone M, Milleri S, Milella M, Butturini G, Salvia R, Bassi C, Melisi D. A phase II study of liposomal irinotecan with 5-fluorouracil, leucovorin and oxaliplatin in patients with resectable pancreatic cancer: the nITRO trial. Ther Adv Med Oncol 2020; 12:1758835920947969. [PMID: 33403007 PMCID: PMC7745557 DOI: 10.1177/1758835920947969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/13/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Up-front surgery followed by postoperative chemotherapy remains the standard paradigm for the treatment of patients with resectable pancreatic cancer. However, the risk for positive surgical margins, the poor recovery after surgery that often impairs postoperative treatment, and the common metastatic relapse limit the overall clinical outcomes achieved with this strategy. Polychemotherapeutic combinations are valid options for postoperative treatment in patients with good performance status. liposomal irinotecan (Nal-IRI) is a novel nanoliposome formulation of irinotecan that accumulates in tumor-associated macrophages improving the therapeutic index of irinotecan and has been approved for the treatment of patients with metastatic pancreatic cancer after progression under gemcitabine-based therapy. Thus, it remains of the outmost urgency to investigate introduction of the most novel agents, such as nal-IRI, in perioperative approaches aimed at increasing the long-term effectiveness of surgery. Methods: The nITRO trial is a phase II, single-arm, open-label study to assess the safety and the activity of nal-IRI with fluorouracil/leucovorin (5-FU/LV) and oxaliplatin in the perioperative treatment of patients with resectable pancreatic cancer. The primary tumor must be resectable with no involvement of the major arteries and no involvement or <180° interface between tumor and vessel wall of the major veins. A total of 72 patients will be enrolled to receive a perioperative treatment of three cycles before and three cycles after surgical resection with nal-IRI 50 mg/m2, oxaliplatin 60 mg/m2, leucovorin 200 mg/m2, and 5-fluorouracil 2400 mg/m2, days 1 and 15 of a 28-day cycle. The primary objective is to improve from 40% to 55% the proportion of patients achieving R0 resection after preoperative treatment. Discussion: The nITRO trial will contribute to strengthen the clinical evidence supporting perioperative strategies in resectable pancreatic cancer patients. Moreover, this study represents a unique opportunity for translational analyses aimed to identify novel immune-related prognostic and predictive factors in this setting. Trial registration Clinicaltrial.gov: NCT03528785. Trial registration data: 1 January 2018 Protocol number: CRC 2017_01 EudraCT Number: 2017-000345-46
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Affiliation(s)
- Francesca Simionato
- Digestive Molecular Clinical Oncology Unit, Section of Medical Oncology, Department of Medicine, University of Verona, Verona, Italy
| | - Camilla Zecchetto
- Digestive Molecular Clinical Oncology Unit, Section of Medical Oncology, Department of Medicine, University of Verona, Verona, Italy
| | - Valeria Merz
- Digestive Molecular Clinical Oncology Unit, Section of Medical Oncology, Department of Medicine, University of Verona, Verona, Italy
| | - Alessandro Cavaliere
- Digestive Molecular Clinical Oncology Unit, Section of Medical Oncology, Department of Medicine, University of Verona, Verona, Italy
| | - Simona Casalino
- Digestive Molecular Clinical Oncology Unit, Section of Medical Oncology, Department of Medicine, University of Verona, Verona, Italy
| | - Marina Gaule
- Digestive Molecular Clinical Oncology Unit, Section of Medical Oncology, Department of Medicine, University of Verona, Verona, Italy
| | - Mirko D'Onofrio
- Department of Radiology, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Landoni
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Alessandro Esposito
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | | | - Luca Casetti
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Massimiliano Tuveri
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Salvatore Paiella
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Filippo Scopelliti
- Department of Surgery, Pancreatic Surgery Unit, Hospital P. Pederzoli, Peschiera del Garda, Italy
| | - Alessandro Giardino
- Department of Surgery, Pancreatic Surgery Unit, Hospital P. Pederzoli, Peschiera del Garda, Italy
| | - Isabella Frigerio
- Department of Surgery, Pancreatic Surgery Unit, Hospital P. Pederzoli, Peschiera del Garda, Italy
| | - Paolo Regi
- Department of Surgery, Pancreatic Surgery Unit, Hospital P. Pederzoli, Peschiera del Garda, Italy
| | - Paola Capelli
- Department of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Stefano Gobbo
- Department of Pathology, Hospital P. Pederzoli, Peschiera del Garda, Italy
| | | | - Laura Bernardoni
- Endoscopy Unit, University and Hospital Trust of Verona, Verona, Italy
| | - Vita Fedele
- Digestive Molecular Clinical Oncology Research Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Irene Rossi
- Centro Ricerche Cliniche di Verona, University and Hospital Trust of Verona, Verona, Italy
| | - Cristiana Piazzola
- Centro Ricerche Cliniche di Verona, University and Hospital Trust of Verona, Verona, Italy
| | - Serena Giacomazzi
- Centro Ricerche Cliniche di Verona, University and Hospital Trust of Verona, Verona, Italy
| | - Martina Pasquato
- Centro Ricerche Cliniche di Verona, University and Hospital Trust of Verona, Verona, Italy
| | - Morena Gianfortone
- Centro Ricerche Cliniche di Verona, University and Hospital Trust of Verona, Verona, Italy
| | - Stefano Milleri
- Centro Ricerche Cliniche di Verona, University and Hospital Trust of Verona, Verona, Italy
| | - Michele Milella
- Medical Oncology Unit, University and Hospital Trust of Verona, Verona, Italy
| | - Giovanni Butturini
- Department of Surgery, Pancreatic Surgery Unit, Hospital P. Pederzoli, Peschiera del Garda, Italy
| | - Roberto Salvia
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Claudio Bassi
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Davide Melisi
- Digestive Molecular Clinical Oncology Unit, Section of Medical Oncology, Department of Medicine, University of Verona, AOUI Verona - Policlinico "G.B. Rossi", Piazzale L.A. Scuro, 10, Verona 37134, Italy
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Bouchart C, Navez J, Closset J, Hendlisz A, Van Gestel D, Moretti L, Van Laethem JL. Novel strategies using modern radiotherapy to improve pancreatic cancer outcomes: toward a new standard? Ther Adv Med Oncol 2020; 12:1758835920936093. [PMID: 32684987 PMCID: PMC7343368 DOI: 10.1177/1758835920936093] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 05/22/2020] [Indexed: 12/11/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains one of the most aggressive solid tumours with an estimated 5-year overall survival rate of 7% for all stages combined. In this highly resistant disease that is located in the vicinity of many radiosensitive organs, the role of radiotherapy (RT) and indications for its use in this setting have been debated for a long time and are still under investigation. Although a survival benefit has yet to be clearly demonstrated for RT, it is the only technique, other than surgery, that has been demonstrated to lead to local control improvement. The adjuvant approach is now strongly challenged by neoadjuvant treatments that could spare patients with rapidly progressive systemic disease from unnecessary surgery and may increase free margin (R0) resection rates for those eligible for surgery. Recently developed dose-escalated RT treatments, designed either to maintain full-dose chemotherapy or to deliver a high biologically effective dose, particularly to areas of contact between the tumour and blood vessels, such as hypofractionated ablative RT (HFA-RT) or stereotactic body RT (SBRT), are progressively changing the treatment landscape. These modern strategies are currently being tested in prospective clinical trials with encouraging preliminary results, paving the way for more effective treatment combinations using novel targeted therapies. This review summarizes the current literature regarding the use of RT for the treatment of primary PDAC, describes the limitations of conventional RT, and discusses the emerging role of dose-escalated RT and heavy-particle RT.
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Affiliation(s)
- Christelle Bouchart
- Department of Radiation-Oncology, Institut Jules Bordet, Boulevard de Waterloo, 121, Brussels, 1000, Belgium
| | - Julie Navez
- Department of Hepato-Biliary-Pancreatic Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Closset
- Department of Hepato-Biliary-Pancreatic Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Hendlisz
- Department of Gastroenterology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Dirk Van Gestel
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Luigi Moretti
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology, Hepatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Chen HY, Wang X, Zhang H, Liu XB, Tan CL. Mesenterico-portal vein invasion should be an important factor in TNM staging for pancreatic ductal adenocarcinoma: Proposed modification of the 8 th edition of the American Joint Committee on Cancer staging system. World J Gastroenterol 2019; 25:6752-6766. [PMID: 31857777 PMCID: PMC6920658 DOI: 10.3748/wjg.v25.i46.6752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/12/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic ductal adenocarcinoma (PDAC) excludes extrapancreatic extension from the assessment of T stage and restages tumors with mesenterico-portal vein (MPV) invasion into T1-3 diseases according to tumor size. However, MPV invasion is believed to be correlated with a poor prognosis.
AIM To analyze whether the inclusion of MPV invasion can further improve the 8th edition of the AJCC staging system for PDAC.
METHODS This study retrospectively included 8th edition AJCC T1-3N0-2M0 patients undergoing pancreaticoduodenectomy/total pancreatectomy from two cohorts and analyzed survival outcomes. In the first cohort, a total of 7539 patients in the surveillance, epidemiology, and end results database was included, and in the second cohort, 689 patients from the West China Hospital database were enrolled.
RESULTS Cox regression analysis showed that MPV invasion is an independent prognostic factor in both databases. In the MPV- group, all pairwise comparisons between the survival functions of patients with different stages were significant except for the comparison between patients with stage IIA and those with stage IIB. However, in the MPV+ group, pairwise comparisons between the survival functions of patients with stage IA, stage IB, stage IIA, stage IIB, and stage III were not significant. T1-3N0 patients in the MPV+ group were compared with the T1N0, T2N0, and T3N0 subgroups of the MPV- group; only the survival of MPV-T3N0 and MPV+T1-3N0 patients had no significant difference. Further comparisons of patients with stage IIA and subgroups of stage IIB showed (1) no significant difference between the survival of T2N1 and T3N0 patients; (2) a longer survival of T1N1 patients that was shorter than the survival of T2N0 patients; and (3) and a shorter survival of T3N1 patients that was similar to that of T1-3N2 patients.
CONCLUSION The modified 8th edition of the AJCC staging system for PDAC proposed in this study, which includes the factor of MPV invasion, provides improvements in predicting prognosis, especially in MPV+ patients.
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Affiliation(s)
- Hong-Yu Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xing Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hao Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xu-Bao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Chun-Lu Tan
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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11
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Clinical impact of additional therapy for residual pancreatic cancer. Surg Today 2019; 50:440-448. [PMID: 31650262 DOI: 10.1007/s00595-019-01900-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to explore the prognostic significance of the resection margin (R) status of pancreatic ductal adenocarcinoma (PDAC) patients receiving neoadjuvant therapy (NAT) or adjuvant chemotherapy (AC). METHODS We retrospectively reviewed 427 consecutive patients, and the overall survival (OS) and disease-free survival (DFS) were analyzed based on the R status by a propensity score analysis (PSA). RESULTS The R0 ratio of the NAT (+) group was significantly higher than that of the NAT (-) group (97.2% vs. 69.6%, P < 0.0001). Local recurrence was well controlled in the NAT (+) group compared to the NAT (-) group (15.3% vs. 34.1%, P = 0.0013). The PSA revealed no significant survival difference between R0 and R1 resection among those treated with AC (median survival time [MST]: 43.0 vs. 33.3 months, matching hazard ratio [HR]: 1.212, P = 0.5708). Furthermore, the DFS in R0 and R1 resection followed by AC was identical (MST: 20.6 vs. 17.7 months, matching HR: 1.020, P = 0.9482). CONCLUSIONS NAT was a significant predictor of R0 resection. When patients completed AC, there were no marked differences in the OS or DFS between R0 and R1 resection. Our results demonstrated that the clinical impact of the R1 status has waned in the current era of PDAC management.
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12
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Hamdy A, Ichikawa Y, Toyomasu Y, Nagata M, Nagasawa N, Nomoto Y, Sami H, Sakuma H. Perfusion CT to Assess Response to Neoadjuvant Chemotherapy and Radiation Therapy in Pancreatic Ductal Adenocarcinoma: Initial Experience. Radiology 2019; 292:628-635. [PMID: 31287389 DOI: 10.1148/radiol.2019182561] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BackgroundChange in tumor size at CT is insufficient for reliable assessment of treatment response after neoadjuvant chemotherapy and radiation therapy (CRT) and shows poor correlation with histologic grading of response.PurposeTo investigate the use of perfusion CT to predict the response of pancreatic ductal adenocarcinoma (PDA) to CRT.Materials and MethodsBetween June 2016 and May 2018, study participants with biopsy-proven PDA were prospectively recruited to undergo perfusion CT before and after planned CRT. Blood flow (BF), blood volume (BV), and permeability-surface area product (PSP) were quantified from CT images. Participants were categorized into responders and nonresponders according to therapy response. The Mann-Whitney test was used to compare the baseline perfusion values between responders and nonresponders, and the Wilcoxon matched-pairs signed rank test was used to compare perfusion values before and after CRT.ResultsThe final cohort of 21 participants (median age, 68 years; interquartile range [IQR], 65-72 years; eight men) underwent dynamic perfusion (dual-source) CT before neoadjuvant CRT. All participants underwent pancreatectomy. Eighteen participants underwent post-CRT perfusion CT. Baseline BF was higher in responders (n = 10) than in nonresponders (n = 11) (median, 44 [IQR, 39-56] vs 28 [IQR, 16-52] mL/100 g/min; P = .04), while BV and PSP were similar between groups (median BV, 4.3 [IQR, 3.5-6.9] vs 2.0 [IQR, 1.6-6.5] mL/100 g, P = .15; median PSP, 25 [IQR, 21-30] vs 20 [IQR, 10-34] mL/100 g/min, P = .31). Response Evaluation Criteria in Solid Tumors (RECIST) and carbohydrate antigen (CA) 19-9 showed no correlation with perfusion parameters (eg, RECIST and BF: r = 0.05, P = .84, 95% confidence interval [CI]: -0.40, 0.48; CA 19-9 and BF: r = 0.06, P = .78, 95% CI: -0.39, 0.49) or histopathologic response (r = 0.16, P = .47, 95% CI: -0.3, 0.57 and r = 0.09, P = .71, 95% CI: -0.37, 0.51, respectively). For responders, perfusion parameters increased after CRT (eg, median BF, 54 [IQR, 42-73] vs 43 [IQR, 28-53] mL/100 g/min; P = .04). The perfusion change in nonresponders was not significant (median BF, 43 [IQR, 28-53] vs 33 [IQR, 16-52] mL/100 g/min; P = .06).ConclusionPerfusion CT may be useful in helping predict the histopathologic response to therapy in pancreatic ductal adenocarcinoma.© RSNA, 2019See also the editorial by Sinitsyn in this issue.
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Affiliation(s)
- Ahmed Hamdy
- From the Department of Radiology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan (A.H., Y.I., Y.T., M.N., N.N., Y.N., H. Sakuma); and Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt (A.H., H. Sami)
| | - Yasutaka Ichikawa
- From the Department of Radiology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan (A.H., Y.I., Y.T., M.N., N.N., Y.N., H. Sakuma); and Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt (A.H., H. Sami)
| | - Yutaka Toyomasu
- From the Department of Radiology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan (A.H., Y.I., Y.T., M.N., N.N., Y.N., H. Sakuma); and Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt (A.H., H. Sami)
| | - Motonori Nagata
- From the Department of Radiology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan (A.H., Y.I., Y.T., M.N., N.N., Y.N., H. Sakuma); and Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt (A.H., H. Sami)
| | - Naoki Nagasawa
- From the Department of Radiology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan (A.H., Y.I., Y.T., M.N., N.N., Y.N., H. Sakuma); and Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt (A.H., H. Sami)
| | - Yoshihito Nomoto
- From the Department of Radiology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan (A.H., Y.I., Y.T., M.N., N.N., Y.N., H. Sakuma); and Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt (A.H., H. Sami)
| | - Haney Sami
- From the Department of Radiology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan (A.H., Y.I., Y.T., M.N., N.N., Y.N., H. Sakuma); and Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt (A.H., H. Sami)
| | - Hajime Sakuma
- From the Department of Radiology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie 514-8507, Japan (A.H., Y.I., Y.T., M.N., N.N., Y.N., H. Sakuma); and Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt (A.H., H. Sami)
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13
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Han S, Choi SH, Choi DW, Heo JS, Han IW, Park DJ, Ryu Y. Neoadjuvant therapy versus upfront surgery for borderline-resectable pancreatic cancer. MINERVA CHIR 2019; 75:15-24. [PMID: 31115240 DOI: 10.23736/s0026-4733.19.07958-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Neoadjuvant therapy is recommended for patients with borderline-resectable pancreatic cancer (BRPC). In this study, we compare survival outcomes of neoadjuvant therapy with upfront surgery. METHODS From January 2011 to June 2016, 1415 patients underwent treatments for pancreatic cancer in Samsung Medical Center. Among them, 112 (7.9%) patients were categorized as BRPC by the NCCN 2016 guideline. They were classified by type of initial treatments into neoadjuvant group (NA, N.=26) and upfront surgery group (US, N.=86). RESULTS The median survival duration of all patients was 18.3 months. Patients in the NA group had more T4 disease than those in the US group (38.5% in NA versus 15.1% in the US group; P=0.010). Arterial involvement was more frequent in the NA group (42.3% versus 15.1%; P=0.003). In the NA group, ten (38.5%) patients underwent surgery, and seven of them had complete R0 resection. In the US group, 83 (96.5%) patients received radical surgery, and 42 (48.8%) had R0 resection. In survival analysis according to intent to treat, the overall two-year survival rate was 51.1% in the US group and 36.7% in the NA group (P=0.001). However, among patients who underwent surgery (N.=96), the two-year overall survival rate was not significantly different between the two groups (P=0.089). According to involved vessels, the survival rate was not different between patients with arterial or both arterial and venous involvement and in patients with only venous involvement (P=0.649). CONCLUSIONS It is necessary to demonstrate the efficacy of neoadjuvant therapy and to standardize the regimens through large-scale, multicenter, randomized controlled studies.
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Affiliation(s)
- Sunjong Han
- Departments of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Sungnam, South Korea
| | - Seong H Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea -
| | - Dong W Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin S Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - In W Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dae-Joon Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Youngju Ryu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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14
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Tummers WS, Groen JV, Sibinga Mulder BG, Farina-Sarasqueta A, Morreau J, Putter H, van de Velde CJ, Vahrmeijer AL, Bonsing BA, Mieog JS, Swijnenburg RJ. Impact of resection margin status on recurrence and survival in pancreatic cancer surgery. Br J Surg 2019; 106:1055-1065. [PMID: 30883699 PMCID: PMC6617755 DOI: 10.1002/bjs.11115] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/29/2018] [Accepted: 12/12/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND The prognosis of patients with pancreatic ductal adenocarcinoma (PDAC) is poor and selection of patients for surgery is challenging. This study examined the impact of a positive resection margin (R1) on locoregional recurrence (LRR) and overall survival (OS); and also aimed to identified tumour characteristics and/or technical factors associated with a positive resection margin in patients with PDAC. METHODS Patients scheduled for pancreatic resection for PDAC between 2006 and 2016 were identified from an institutional database. The effect of resection margin status, patient characteristics and tumour characteristics on LRR, distant metastasis and OS was assessed. RESULTS A total of 322 patients underwent pancreatectomy for PDAC. A positive resection (R1) margin was found in 129 patients (40·1 per cent); this was associated with decreased OS compared with that in patients with an R0 margin (median 15 (95 per cent c.i. 13 to 17) versus 22 months; P < 0·001). R1 status was associated with reduced time to LRR (median 16 versus 36 (not estimated, n.e.) months; P = 0·002). Disease recurrence patterns were similar in the R1 and R0 groups. Risk factors for early recurrence were tumour stage, positive lymph nodes (N1) and perineural invasion. Among 100 patients with N0 disease, R1 status was associated with shorter OS compared with R0 resection (median 17 (10 to 24) versus 45 (n.e.) months; P = 0·002), whereas R status was not related to OS in 222 patients with N1 disease (median 14 (12 to 16) versus 17 (15 to 19) months after R1 and R0 resection respectively; P = 0·068). CONCLUSION Although pancreatic resection with a positive margin was associated with poor survival and early recurrence, particularly in patients with N1 disease, disease recurrence patterns were similar between R1 and R0 groups.
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Affiliation(s)
- W S Tummers
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - J V Groen
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - B G Sibinga Mulder
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - A Farina-Sarasqueta
- Department of Pathology, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Morreau
- Department of Pathology, Leiden University Medical Centre, Leiden, the Netherlands
| | - H Putter
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, the Netherlands
| | - C J van de Velde
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - J S Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - R J Swijnenburg
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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15
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Venkatesulu BP, Hsieh CE, Sanders KL, Krishnan S. Recent advances in radiation therapy of pancreatic cancer. F1000Res 2018; 7:F1000 Faculty Rev-1931. [PMID: 30613390 PMCID: PMC6305239 DOI: 10.12688/f1000research.16272.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2018] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer has a dismal prognosis with an overall survival outcome of just 5% at five years. However, paralleling our improved understanding of the biology of pancreatic cancer, treatment paradigms have also continued to evolve with newer advances in surgical techniques, chemotherapeutic agents, radiation therapy (RT) techniques, and immunotherapy paradigms. RT dose, modality, fraction size, and sequencing are being evaluated actively, and the interplay between RT and immune effects has opened up newer avenues of research. In this review, we will emphasize recent advances in RT for pancreatic cancer, focusing on preoperative chemoradiation, RT dose escalation, sparing of the spleen to reduce lymphopenia, and combination of RT with immunotherapy.
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Affiliation(s)
- Bhanu Prasad Venkatesulu
- Department of Experimental Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cheng-En Hsieh
- Department of Experimental Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- The University of Texas MD Anderson Cancer Center-UT Health Graduate School of Biomedical Sciences, Houston, TX, USA
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Taoyuan, Taiwan
| | - Keith L Sanders
- Department of Experimental Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunil Krishnan
- Department of Experimental Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- The University of Texas MD Anderson Cancer Center-UT Health Graduate School of Biomedical Sciences, Houston, TX, USA
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16
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Barton S, Li B, Siuta M, Vaibhav J, Song J, Holt CM, Tomono T, Ukawa M, Kumagai H, Tobita E, Wilson K, Sakuma S, Pham W. SPECIFIC MOLECULAR RECOGNITION AS A STRATEGY TO DELINEATE TUMOR MARGIN USING TOPICALLY APPLIED FLUORESCENCE EMBEDDED NANOPARTICLES. PRECISION NANOMEDICINE 2018; 1:194-207. [PMID: 31773101 DOI: 10.33218/prnano1(3).181009.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The Thomsen-Friedenreich (TF) antigen is a tumor-associated antigen consistently expressed on the apical surface of epithelial-based cancer cells, including pancreatic cancer. In this work, we report the development of multimodal imaging probe, the tripolymer fluorescent nanospheres, whose surface was fabricated with peanut agglutinin (PNA) moieties as TF molecular recognition molecules. Here, we demonstrate that the probe is able to detect TF antigen in human pancreatic cancer tissues and differentiate from normal tissue. What is most noteworthy regarding the probe is its ability to visualize tumor margins defined by epithelial TF antigen expression. Further, in vivo preclinical studies using an orthotopic mouse model of pancreatic cancer suggest the potential use of the nanospheres for laparoscopic imaging of pancreatic cancer tumor margins to enhance surgical resection and improve clinical outcomes.
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Affiliation(s)
- Shawn Barton
- Vanderbilt University Institute of Imaging Science, Nashville, TN
| | - Bo Li
- Vanderbilt University Institute of Imaging Science, Nashville, TN
| | - Michael Siuta
- Vanderbilt University Institute of Imaging Science, Nashville, TN
| | - Janve Vaibhav
- Vanderbilt University Institute of Imaging Science, Nashville, TN
| | - Jessica Song
- Vanderbilt University Institute of Imaging Science, Nashville, TN
| | - Clinton M Holt
- Vanderbilt University Institute of Imaging Science, Nashville, TN
| | - Takumi Tomono
- Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Osaka, Japan
| | - Masami Ukawa
- Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Osaka, Japan
| | | | - Etsuo Tobita
- Advanced Materials R&D Laboratory, ADEKA Corp., Tokyo, Japan
| | - Kevin Wilson
- Vanderbilt University Institute of Imaging Science, Nashville, TN
| | - Shinji Sakuma
- Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Osaka, Japan
| | - Wellington Pham
- Vanderbilt University Institute of Imaging Science, Nashville, TN.,Department of Radiology and Radiological Sciences, Vanderbilt University, Nashville, TN.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN.,Vanderbilt Ingram Cancer Center, Vanderbilt School of Medicine Nashville, TN.,Vanderbilt Brain Institute, Nashville, Vanderbilt University, TN.,Vanderbilt Institute of Chemical Biology, Nashville, TN
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17
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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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18
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Lauffer DC, Kuhn PA, Kueng M, Thalmann SU, Risse G, Tercier PA, Egger B, Allal AS. Pancreatic Cancer: Feasibility and Outcome After Radiochemotherapy with High Dose External Radiotherapy for Non-resected and R1 Resected Patients. Cureus 2018; 10:e2713. [PMID: 30079279 PMCID: PMC6067808 DOI: 10.7759/cureus.2713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Non-resected locally advanced and microscopic positive-margin resected (R1) pancreatic adenocarcinoma are associated with a dismal prognosis. The combination of high dose radiotherapy and concomitant chemotherapy is among the strategies that are used to improve the outcome. The aims of this study were to evaluate the acute and late toxicities and patients' outcome in a retrospective study from a single center. Material and methods From 2009 to 2015, 24 patients, with non-resected locally advanced or R1 resected pancreatic adenocarcinoma, have been treated with concomitant radiochemotherapy, with a median dose of 60 Gy and gemcitabine (50 mg/m2 administered bi-weekly). The acute and late toxicities were evaluated during and after the treatment. Results The actuarial overall survival rates were 39% at 24 months and 8.6% at 36 months. The disease-free survival rates were 32.5% at 24 months and 12.2% at 36 months. Acute toxicities were mainly grade 1 (G1) to grade 2 (G2) except for one patient who presented with severe digestive bleeding potentially linked to the treatment. Late toxicities consisted mainly of G1 digestive toxicities. Conclusion This study confirms the feasibility of high dose radiotherapy combined with gemcitabine-based chemotherapy in patients with locally advanced pancreatic adenocarcinoma. While the outcome remains unsatisfactory, some patients seem to have benefited from this aggressive therapy, which merits to be investigated further.
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Affiliation(s)
- David C Lauffer
- Department of Radiation Oncology, Hospital of Fribourg, Bern, CHE
| | - Peter A Kuhn
- Department of Radiation Oncology, Hospital of Fribourg, Fribourg, CHE
| | - Marc Kueng
- Department of Medical Oncology, Hospital of Fribourg, Fribourg, CHE
| | | | - Géraldine Risse
- Department of Radiation Oncology, Hospital of Fribourg, Fribourg, CHE
| | | | - Bernhard Egger
- Department of General Surgery, Hospital of Fribourg, Fribourg, CHE
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19
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Morganti AG, Trodella L, Valentini V, Doglietto GB, Ziccarelli P, Macchia G, Alfieri S, Smaniotto D, Luzi S, Brizi MG, Fadda G, Fiorino M, Di Gesù C, Cellini N. La Radiochemioterapia Preoperatoria Del Carcinoma Pancreatico: Risultati Preliminari. TUMORI JOURNAL 2018. [DOI: 10.1177/030089169908501s08] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Alessio G. Morganti
- Istituto di Radiologia, Cattedra di Radioterapia; Istituto di Clinica Chirurgica, Roma
| | - Lucio Trodella
- Istituto di Radiologia, Cattedra di Radioterapia; Istituto di Clinica Chirurgica, Roma
| | - Vincenzo Valentini
- Istituto di Radiologia, Cattedra di Radioterapia; Istituto di Clinica Chirurgica, Roma
| | | | - Pierpaolo Ziccarelli
- Istituto di Radiologia, Cattedra di Radioterapia; Istituto di Clinica Chirurgica, Roma
| | - Gabriella Macchia
- Istituto di Radiologia, Cattedra di Radioterapia; Istituto di Clinica Chirurgica, Roma
| | | | - Daniela Smaniotto
- Istituto di Radiologia, Cattedra di Radioterapia; Istituto di Clinica Chirurgica, Roma
| | - Stefano Luzi
- Istituto di Radiologia, Cattedra di Radioterapia; Istituto di Clinica Chirurgica, Roma
| | - M. Gabriella Brizi
- Istituto di Radiologia, Cattedra di Radioterapia; Istituto di Clinica Chirurgica, Roma
| | | | | | - Cinzia Di Gesù
- Istituto di Radiologia, Cattedra di Radioterapia; Istituto di Clinica Chirurgica, Roma
| | - Numa Cellini
- Istituto di Radiologia, Cattedra di Radioterapia; Istituto di Clinica Chirurgica, Roma
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Regine WF, Winter K, Abrams RA, Safran H, Kessel IL, Chen Y, Fugazzi JA, Donnelly ED, DiPetrillo TA, Narayan S, Plastaras JP, Gaur R, Delouya G, Suh JH, Meyer JE, Haddock MG, Didolkar MS, Padula GDA, Johnson D, Hoffman JP, Crane CH. Postresection CA19-9 and margin status as predictors of recurrence after adjuvant treatment for pancreatic carcinoma: Analysis of NRG oncology RTOG trial 9704. Adv Radiat Oncol 2018; 3:154-162. [PMID: 29904740 PMCID: PMC6000159 DOI: 10.1016/j.adro.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/16/2018] [Indexed: 12/30/2022] Open
Abstract
Purpose NRG Oncology RTOG 9704 was the first adjuvant trial to validate the prognostic value of postresection CA19-9 levels for survival in patients with pancreatic carcinoma. The data resulting from this study also provide information about predictors of recurrence that may be used to tailor individualized management in this disease setting. This secondary analysis assessed the prognostic value of postresection CA19-9 and surgical margin status (SMS) in predicting patterns of disease recurrence. Methods and materials This multicenter cooperative trial included participants who were enrolled as patients at oncology treatment sites in the United States and Canada. The study included 451 patients analyzable for SMS, of whom 385 were eligible for postresection CA19-9 analysis. Postresection CA19-9 was analyzed at cut points of 90, 180, and continuously. Patterns of disease recurrence included local/regional recurrence (LRR) and distant failure (DF). Multivariable analyses included treatment, tumor size, and nodal status. To adjust for multiple comparisons, a P value of ≤ .01 was considered statistically significant and > .01 to ≤ .05 to be a trend. Results For CA19-9, 132 (34%) patients were Lewis antigen-negative (no CA19-9 expression), 200 (52%) had levels <90, and 220 (57%) had levels <180. A total of 188 patients (42%) had negative margins, 152 (34%) positive, and 111 (25%) unknown. On univariate analysis, CA19-9 cut at 90 was associated with increases in LRR (trend) and DF. Results were similar at the 180 cut point. SMS was not associated with an increase in LRR on univariate or multivariate analyses. On multivariable analysis, CA19-9 ≥ 90 was associated with increased LRR and DF. Results were similar at the 180 cut point. Conclusions In this prospective evaluation, postresection CA19-9 was a significant predictor of both LRR and DF, whereas SMS was not. These findings support consideration of adjuvant radiation therapy dose intensification in patients with elevated postresection CA19-9.
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Affiliation(s)
| | - Kathryn Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | | | - Ivan L Kessel
- University of Texas Medical Branch, Galveston, Texas
| | - Yuhchyau Chen
- University of Rochester Medical Center, Rochester, New York
| | - James A Fugazzi
- Toledo Community Hospital Oncology Program CCOP, Toledo, Ohio
| | | | | | - Samir Narayan
- Michigan Cancer Research Consortium CCOP, Ann Arbor, Michigan
| | - John P Plastaras
- University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | | | - Guila Delouya
- Centre Hospitalier de l'Université de Montréal-Notre Dame, Montreal, Quebec
| | - John H Suh
- Cleveland Clinic Foundation, Cleveland, Ohio
| | | | | | | | | | | | | | - Christopher H Crane
- The University of Texas MD Anderson Cancer Center, Houston, Texas.,Memorial Sloan Kettering Cancer Center, New York, New York
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Macchia G, Valentini V, Mattiucci GC, Mantini G, Alfieri S, Digesù C, Deodato F, Trodella L, Doglietto GB, Cellini N, Morganti AG. Preoperative Chemoradiation and Intra-Operative Radiotherapy for Pancreatic Carcinoma. TUMORI JOURNAL 2018; 93:53-60. [PMID: 17455872 DOI: 10.1177/030089160709300110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aims and background In recent years, preoperative chemoradiation has received growing interest for the treatment of locally advanced pancreatic cancer. In an attempt to improve resectability and disease control, we used preoperative radiation therapy and concomitant 5-fluorouracil in a combined modality therapy protocol. The aim of the study was to evaluate definitive results in terms of toxicity, response and clinical outcome. Material and methods Twenty-eight patients with unresectable (cT4,19 patients) or resectable (cT3, 9 patients) nonmetastatic pancreatic tumors received radiotherapy (39.6 Gy) plus 5-fluorouracil (continuous infusion, days 1-4 at 1000 mg/m2/day). After 4 weeks, patients were evaluated for surgical resection. In 9 resected patients, electron-beam intra-operative radiotherapy (10 Gy) was given before reconstruction. Thereafter, in resected patients, adjuvant chemotherapy was prescribed. Results During chemoradiation, 1 patient (3.6%) developed grade 3 acute gastrointestinal toxicity and 2 patients (7.1%) developed grade 3 hematological toxicity. Three of 19 patients with unresectable tumors had tumor downstaging (15.8%). Two patients showed partial response (response rate, 7.1%; 95% CI, 0.2-25.3) and 4 patients (14.3%) had minimal tumor response. Four patients (14.3%) showed progressive disease after chemoradiation. One postoperative death was recorded. The median survival time was 11.3 months (20.5 and 9.0 months in resected and unresected patients, respectively). Only one local failure was recorded in 8 patients resected with negative margins. Conclusions Although the response rate is still low, our preliminary results suggest that preoperative 5-fluorouracil chemoradiation is well tolerated and may result in tumor downstaging. Delivery of intra-operative radiotherapy seems to be associated with a low rate of local recurrences.
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Affiliation(s)
- Gabriella Macchia
- Unità Operativa di Radioterapia, Universitti Cattolica del S. Cuore, Campobasso.
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Torgeson A, Garrido-Laguna I, Tao R, Cannon GM, Scaife CL, Lloyd S. Value of surgical resection and timing of therapy in patients with pancreatic cancer at high risk for positive margins. ESMO Open 2018; 3:e000282. [PMID: 29387477 PMCID: PMC5786921 DOI: 10.1136/esmoopen-2017-000282] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/11/2017] [Accepted: 11/13/2017] [Indexed: 12/23/2022] Open
Abstract
Background Surgical resection remains the best chance at long-term survival in pancreatic cancer, though margin-positive resections are associated with diminished survival. We examined the effect of margin-positive resection on survival, as well as the role and timing of additional therapies through the National Cancer Database (NCDB). Patients and methods Patients with stage IIA–III pancreatic adenocarcinoma diagnosed from 2004 to 2013 were identified in NCDB. Survival was compared using univariate and multivariate Cox proportional hazards modelling for patients who underwent surgery with negative (R0), microscopically positive (R1) and macroscopically positive (R2) margins or non-surgical treatment. We further analysed patients by margin status, timing of additional therapy (neoadjuvant therapy (NAT) vs adjuvant therapy (AT) vs none) and clinical stage. Results We analysed 44 852 patients. Median survival (MS) for patients who did not undergo surgery was 10.3 months, compared with 19.7 months for R0 (P<0.001), 14.3 months for R1 (P<0.001) and 9.8 months (P=0.07) for R2 resections. NAT (MS 23.2 months) was associated with improved survival compared with AT (MS 21.5 months) in negative-margin patients and equivalent (MS 17.6 months) to AT (MS 16.8 months) in positive-margin patients. Survival for stage III NAT positive-margin patients (MS 19.8 months) was equivalent to AT after negative margins (MS 18.4 months, P=1.00). Improved R0 rates were seen with NAT (88% vs 81%, P<0.001), especially in stage III patients (85% vs 59%, P<0.001). Conclusion R1 resections portend poorer survival than R0 but do not negate the benefit of surgery when additional therapy is given. NAT was associated with improved R0 rates and improved survival for stage III positive-margin patients.
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Affiliation(s)
- Anna Torgeson
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Ignacio Garrido-Laguna
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Randa Tao
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - George M Cannon
- Department of Radiation Oncology, Intermountain Medical Center, Murray, Utah, USA
| | - Courtney L Scaife
- Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Shane Lloyd
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
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Should functional renal scans be obtained prior to upper abdominal IMRT for pancreatic cancer? Pract Radiat Oncol 2017; 7:e449-e455. [PMID: 28886941 DOI: 10.1016/j.prro.2017.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/08/2017] [Accepted: 06/26/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Upper abdominal irradiation for pancreatic cancer is administered in close proximity to the radiation-sensitive kidneys. There is difficulty in defining dose-volume parameters to predict late renal toxicity after partial kidney irradiation. Less than 10% of the general population is estimated to have asymmetrical kidney function; however, there are no studies that examine this in patients with pancreatic cancer. The primary purpose of this study was to determine the prevalence of asymmetrical kidney function in patients with pancreatic cancer. A secondary aim was to determine if asymmetrical kidney function was associated with abnormal laboratory values or kidney size on computed tomography scans. Finally, we aimed to develop recommendations for when a functional renal scan in patients with pancreatic cancer should be ordered. METHODS AND MATERIALS We performed a retrospective review of patients with resectable, borderline resectable, and locally advanced pancreatic cancer who received abdominal radiation therapy and had preradiation functional renal scans between 2009 and 2015. Asymmetrical kidney function was defined as a difference between the 2 kidneys that was ≥60%/40% on a functional renal scan. Serum studies (blood urea nitrogen [BUN], creatinine [Cr], and glomerular filtration rate [GFR]) and abdominal computed tomography scans were routinely obtained before simulation. RESULTS Of the 204 patients examined, 23 (11.2%) had asymmetrical kidney function that was identified on preradiation functional renal scans. Elevated Cr or BUN, a GFR <60, or a medical history that suggested abnormal renal function were not significantly associated with asymmetrical kidney function. Only 6 of 23 patients (26%) with asymmetrical kidney function had a notable difference in kidney size. CONCLUSIONS In our series, approximately 11% of patients with pancreatic cancer have asymmetrical kidney function that was not identified by kidney size, serum BUN, Cr, GFR, or a significant medical history. These data suggest that in cases in which renal radiation doses exceed a V18 of 20% to 30% or there is concern about baseline renal function, a functional renal scan should be considered.
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Zervos EE, Rosemurgy AS, Al-Saif O, Durkin AJ. Surgical Management of Early-Stage Pancreatic Cancer. Cancer Control 2017. [DOI: 10.1177/107327480401100204] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Neoadjuvant Therapy for Pancreatic Cancer: Systematic Review of Postoperative Morbidity, Mortality, and Complications. Am J Clin Oncol 2017; 39:302-13. [PMID: 26950464 DOI: 10.1097/coc.0000000000000278] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this review was to assess whether neoadjuvant chemotherapy and chemoradiotherapy (CRT) result in differential postoperative morbidity and mortality as compared with pancreatic tumor resection surgery alone. Using PRISMA guidelines and the PubMed search engine, we reviewed all prospective phase II trials of neoadjuvant chemotherapy and CRT for pancreatic cancer that examined postoperative morbidities and mortalities. A total of 30 articles were identified, collated, and analyzed. Risks of postoperative complications vary based on trial. With surgery alone, the most common postoperative complications included delayed gastric emptying (DGE) (17% to 24%), pancreatic fistula (10% to 20%), anastomotic leaks (0% to 15%), postoperative bleeding (2% to 13%), and infections/sepsis (17% to 20%). With surgery alone, the mortality was <5%. Neoadjuvant chemotherapy showed comparable fistula rates (3% to 4%), leaks (3% to 11%), infection (3% to 7%), with mortality 0% to 4% in all but 1 study. CRT for resectable/borderline resectable patients also showed comparable complication rates: DGE (6% to 15%), fistulas (2% to 3%), leaks (3% to 7%), bleeding/hemorrhage (2% to 13%), infections/sepsis (3% to 19%), with 9/13 studies showing a mortality of ≤4%. As compared with initially borderline/resectable tumors, CRT for initially unresectable tumors (despite less data) showed higher complication rates: DGE (13% to 33%), fistulas (3% to 25%), infections/sepsis (3% to 16%). However, the confounding factor of the potentially higher tumor burden as an associative agent remains. The only parameters slightly higher than historical surgery-only complication rates were leaks and bleeding/hemorrhage (13% to 20%). Mortality rates in these patients were consistently 0%, with 2 outliers. Hence, neoadjuvant chemotherapy/CRT is safe from a postoperative complication standpoint, without significant increases in complication rates compared with surgery alone. Resectable and borderline resectable patients have fewer complications as compared with unresectable patients, although data for the latter are lacking.
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Okano K, Suto H, Oshima M, Maeda E, Yamamoto N, Kakinoki K, Kamada H, Masaki T, Takahashi S, Shibata T, Suzuki Y. A Prospective Phase II Trial of Neoadjuvant S-1 with Concurrent Hypofractionated Radiotherapy in Patients with Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2017; 24:2777-2784. [PMID: 28608121 DOI: 10.1245/s10434-017-5921-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The ideal neoadjuvant treatment protocol for patients with pancreatic cancer (PDAC) remains unclear. We evaluated the efficacy and safety of neoadjuvant hypofractionated chemoradiotherapy with S-1 for patients with resectable (R) and borderline resectable (BR) PDAC. METHODS Eligibility criteria included patients with R and BR PDAC, performance status 0-1, and age 20-85 years. Hypofractionated external-beam radiotherapy (30 Gy in 10 fractions) with concurrent S-1 (60 mg/m2) was delivered 5 days/week for 2 weeks prior to pancreatectomy. RESULTS Fifty-seven patients were enrolled in this study, including 33 R and 24 BR [19 BR tumors with portal vein contact (BR-PV) and 5 BR tumors with arterial contact (BR-A)]. The total rates of protocol treatment completion and resection were 91% (50/57) and 96% (55/57), respectively. Seven patients failed to complete S-1 due to cholangitis (n = 5) or neutropenia (n = 2). The most common grade 3 toxicities [Common Terminology Criteria for Adverse Events (CTCAE) version 4.0] were anorexia (7%), nausea (5%), neutropenia (4%), and leukopenia (4%). No patient experienced grade 4 toxicity. Pathologically negative margins (R0) were achieved in 54 of 55 patients (98%) who underwent pancreatectomy. Pathological response was classified as Evans grade I in 8 patients (15%), IIa in 31 patients (56%), IIb in 14 patients (25%), III in 1 patient (2%), and IV in 1 patient (2%), and operative morbidity (Clavien-Dindo grade IIIb or less) was observed in 4 patients (8%). The 1- and 2-year overall survival (OS) rates were 91 and 83% in R patients, respectively, and 77 and 58% in BR patients, respectively (p = 0.03). CONCLUSION Neoadjuvant S-1 with concurrent hypofractionated radiotherapy is tolerable and appears promising for patients with R and BR PDAC.
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Affiliation(s)
- Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan.
| | - Hironobu Suto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Minoru Oshima
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Eri Maeda
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Naoki Yamamoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Keitaro Kakinoki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Hideki Kamada
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Shigeo Takahashi
- Department of Radiation Oncology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Toru Shibata
- Department of Radiation Oncology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
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Pancreatic Cancer: 80 Years of Surgery-Percentage and Repetitions. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2016; 2016:6839687. [PMID: 27847403 PMCID: PMC5099466 DOI: 10.1155/2016/6839687] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/01/2016] [Indexed: 12/18/2022]
Abstract
Objective. The incidence of pancreatic cancer is estimated to be 48,960 in 2015 in the US and projected to become the second and third leading causes of cancer-related deaths by 2030. The mean costs in 2015 may be assumed to be $79,800 per patient and for each resection $164,100. Attempt is made to evaluate the results over the last 80 years, the number of survivors, and the overall survival percentage. Methods. Altogether 1230 papers have been found which deal with resections and reveal survival information. Only 621 of these report 5-year survivors. Reservation about surgery was first expressed in 1964 and five-year survival of nonresected survivors is well documented. Results. The survival percentage depends not only on the number of survivors but also on the subset from which it is calculated. Since the 1980s the papers have mainly reported the number of resections and survival as actuarial percentages, with or without the actual number of survivors being reported. The actuarial percentage is on average 2.75 higher. Detailed information on the original group (TN), number of resections, and actual number of survivors is reported in only 10.6% of the papers. Repetition occurs when the patients from a certain year are reported several times from the same institution or include survivors from many institutions or countries. Each 5-year survivor may be reported several times. Conclusion. Assuming a 10% resection rate and correcting for repetitions and the life table percentage the overall actual survival rate is hardly more than 0.3%.
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Tsai S, Erickson BA, Dua K, Ritch PS, Tolat P, Evans DB. Evolution of the Management of Resectable Pancreatic Cancer. J Oncol Pract 2016; 12:772-8. [DOI: 10.1200/jop.2016.015818] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
In pancreatic cancer, as with many other solid tumors, a commonly held surgical adage—a chance to cut is a chance to cure—has been promulgated throughout the years. Following such reasoning, surgical extirpation of a localized tumor would prevent tumor dissemination and metastatic tumor progression. However, decades of surgical experience have demonstrated that surgical resection alone provides a limited median survival benefit. Despite the optimization of surgical technique and perioperative management over the past three decades, little progress has been made to improve the limited survival of patients with localized pancreatic cancer who receive surgery. In this article, we discuss the rationale for a novel management strategy for patients with resectable pancreatic cancer, which may improve patient selection and the delivery of multimodality therapy.
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Affiliation(s)
- Susan Tsai
- Medical College of Wisconsin, Milwaukee, WI
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Russo S, Wasif Saif M. Neoadjuvant therapy for pancreatic cancer: an ongoing debate. Therap Adv Gastroenterol 2016; 9:429-36. [PMID: 27366211 PMCID: PMC4913343 DOI: 10.1177/1756283x16646524] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Suzanne Russo
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Hafeez Bhatti AB, Dar FS, Sahaab E, Khan NY, Zia H, Rana A, Salih M, Shah NH. Survival advantage with para aortic lymphadenectomy in peri-ampullary cancer: A retrospective cohort study. Int J Surg 2016; 31:58-62. [PMID: 27262530 DOI: 10.1016/j.ijsu.2016.05.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/15/2016] [Accepted: 05/28/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Metastatic para aortic lymph nodes (PALN) in patients with peri ampullary cancer entail poor prognosis. Role of curative surgery in these patients remains debatable. The objective of the current study was to evaluate outcome after extended pancreaticoduodenectomy (PD) in patients with and without positive PALN. METHODS We reviewed 65 patients who underwent extended PD with PALN removal between 2011 and 2014. Patients were divided into two groups; those with positive PALN and those without. Patients were sub classified for pancreatic and non-pancreatic cancer. Outcome was determined based on median and estimated 3 year overall survival. RESULTS Median age was 57 (32-85) years. PALN were involved in 15 (23%) patients. Overall 3 year survival for patients with and without positive PALN was 60% and 54% (P = 0.7). Significant difference in survival was present between patients with pancreatic cancer and positive PALN [9 (3-12) months] versus non-pancreatic cancers with positive PALN [17.5 (13-38) months] (P = 0.02). Four out of five patients with pancreatic cancer and positive PALN had survival >6 months and 3 out of these 5 patients were alive at the last follow up. CONCLUSION Curative surgery may benefit some patients with pancreatic cancer and positive PALN and should be considered selectively.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan.
| | - Faisal Saud Dar
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Eraj Sahaab
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Nusrat Yar Khan
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Haseeb Zia
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Atif Rana
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Muhammad Salih
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Pakistan
| | - Najmul Hassan Shah
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Pakistan
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Shaib WL, Hawk N, Cassidy RJ, Chen Z, Zhang C, Brutcher E, Kooby D, Maithel SK, Sarmiento JM, Landry J, El-Rayes BF. A Phase 1 Study of Stereotactic Body Radiation Therapy Dose Escalation for Borderline Resectable Pancreatic Cancer After Modified FOLFIRINOX (NCT01446458). Int J Radiat Oncol Biol Phys 2016; 96:296-303. [PMID: 27475674 DOI: 10.1016/j.ijrobp.2016.05.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/29/2016] [Accepted: 05/10/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE A challenge in borderline resectable pancreatic cancer (BRPC) management is the high rate of positive posterior margins (PM). Stereotactic body radiation therapy (SBRT) allows for higher radiation delivery dose with conformity. This study evaluated the maximal tolerated dose with a dose escalation plan level up to 45 Gy using SBRT in BRPC. METHODS AND MATERIALS A single-institution, 3 + 3 phase 1 clinical trial design was used to evaluate 4 dose levels of SBRT delivered in 3 fractions to the planning target volume (PTV) with a simultaneous in-field boost (SIB) to the PM. Dose level (DL) 1 was 30 Gy to the PTV, and for dose levels 2 through 4 (DL2-DL4) the dose was 36 Gy. The SIB dose to the PM was 6, 6, 7.5, and 9 Gy for DL-1, DL-2, DL-3, and DL-4, respectively. All patients received 4 treatments of modified FOLFIRINOX (fluorouracil, leucovorin, irinotecan, oxaliplatin) before SBRT. RESULTS Thirteen patients with a median age of 64 years were enrolled. The median follow-up time was 18 months. The locations of the cancer were head (n=12) and uncinate/neck (n=1). One patient did not undergo SBRT. There were no grade 3 or 4 toxicities. Five patients did not undergo resection because of disease progression (1 local, 4 distant); 8 had R0 resection in the PM, and 5 of 8 had vessel reconstruction. Two patients had disease downstaged to T1 and T2 from T3 disease. Four patients are still alive, and 3 are disease free. The median overall survival for resected patients was not reached (9.3: not reached). CONCLUSION The SBRT dose of 36 Gy with a 9-Gy SIB to the PM (total 45 Gy) delivered in 3 fractions is safe and well tolerated. The dose-limiting toxicity for a 45-Gy dose was not reached, and further dose escalations are needed in future trials.
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Affiliation(s)
- Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Natalyn Hawk
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Richard J Cassidy
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Zhengjia Chen
- Department of Biostatistics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Chao Zhang
- Department of Biostatistics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Edith Brutcher
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David Kooby
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Juan M Sarmiento
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jerome Landry
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bassel F El-Rayes
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.
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Butler JR, Ahmad SA, Katz MH, Cioffi JL, Zyromski NJ. A systematic review of the role of periadventitial dissection of the superior mesenteric artery in affecting margin status after pancreatoduodenectomy for pancreatic adenocarcinoma. HPB (Oxford) 2016; 18:305-11. [PMID: 27037198 PMCID: PMC4814605 DOI: 10.1016/j.hpb.2015.11.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 11/02/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Resectable pancreatic ductal adenocarcinoma continues to carry a poor prognosis. Of the controllable clinical variables known to affect outcome, margin status is paramount. Though the importance of a R0 resection is generally accepted, not all margins are easily managed. The superior mesenteric artery [SMA] in particular is the most challenging to clear. The aim of this study was to systematically review the literature with specific focus on the role of a SMA periadventitial dissection during PD and it's effect on margin status in pancreatic adenocarcinoma. STUDY DESIGN The MEDLINE, EMBASE and Cochrane databases were searched for abstracts that addressed the effect of margin status on survival and recurrence following pancreaticoduodenectomy [PD]. Quantitative analysis was performed. RESULTS The overall incidence of a R1 resection ranged from 16% to 79%. The margin that was most often positive following PD was the SMA margin, which was positive in 15-45% of resected specimens. Most studies suggested that a positive margin was associated with decreased survival. No consistent definition of R0 resection was observed. CONCLUSIONS Margin positivity in resectable pancreatic adenocarcinoma is associated with poor survival. Inability to clear the SMA margin is the most common cause of incomplete resection. More complete and consistently reported data are needed to evaluate the potential effect of periadventitial SMA dissection on margin status, local recurrence, or survival.
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Affiliation(s)
- James R. Butler
- Indiana University School of Medicine, Department of Surgery, Indianapolis IN, USA
| | - Syed A. Ahmad
- The University of Cincinnati Cancer Institute, Cincinnati OH, USA
| | - Matthew H. Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica L. Cioffi
- Indiana University School of Medicine, Department of Surgery, Indianapolis IN, USA
| | - Nicholas J. Zyromski
- Indiana University School of Medicine, Department of Surgery, Indianapolis IN, USA,Correspondence Nicholas J. Zyromski, MD, Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Emerson Hall 519, Indianapolis, IN 46202, USA. Tel: +1 317 274 5012.
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Roeder F. Neoadjuvant radiotherapeutic strategies in pancreatic cancer. World J Gastrointest Oncol 2016; 8:186-197. [PMID: 26909133 PMCID: PMC4753169 DOI: 10.4251/wjgo.v8.i2.186] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/12/2015] [Accepted: 12/11/2015] [Indexed: 02/05/2023] Open
Abstract
This review summarizes the current status of neoadjuvant radiation approaches in the treatment of pancreatic cancer, including a description of modern radiation techniques, and an overview on the literature regarding neoadjuvant radio- or radiochemotherapeutic strategies both for resectable and irresectable pancreatic cancer. Neoadjuvant chemoradiation for locally-advanced, primarily non- or borderline resectable pancreas cancer results in secondary resectability in a substantial proportion of patients with consecutively markedly improved overall prognosis and should be considered as possible alternative in pretreatment multidisciplinary evaluations. In resectable pancreatic cancer, outstanding results in terms of response, local control and overall survival have been observed with neoadjuvant radio- or radiochemotherapy in several phase I/II trials, which justify further evaluation of this strategy. Further investigation of neoadjuvant chemoradiation strategies should be performed preferentially in randomized trials in order to improve comparability of the current results with other treatment modalities. This should include the evaluation of optimal sequencing with newer and more potent systemic induction therapy approaches. Advances in patient selection based on new molecular markers might be of crucial interest in this context. Finally modern external beam radiation techniques (intensity-modulated radiation therapy, image-guided radiation therapy and stereotactic body radiation therapy), new radiation qualities (protons, heavy ions) or combinations with alternative boosting techniques widen the therapeutic window and contribute to the reduction of toxicity.
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Russo S, Ammori J, Eads J, Dorth J. The role of neoadjuvant therapy in pancreatic cancer: a review. Future Oncol 2016; 12:669-85. [PMID: 26880384 DOI: 10.2217/fon.15.335] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Controversy remains regarding neoadjuvant approaches in the treatment of pancreatic cancer. Neoadjuvant therapy has several potential advantages over adjuvant therapy including earlier delivery of systemic treatment, in vivo assessment of response, increased resectability rate in borderline resectable patients and increased margin-negative resection rate. At present, there are no randomized data favoring neoadjuvant over adjuvant therapy and multiple neoadjuvant approaches are under investigation. Combination chemotherapy regimens including 5-fluorouracil, irinotecan and oxaliplatin, gemcitabine with or without abraxane, or docetaxel and capecitabine have been used in the neoadjuvant setting. Radiation and chemoradiation have also been incorporated into neoadjuvant strategies, and delivery of alternative fractionation regimens is being explored. This review provides an overview of neoadjuvant therapies for pancreatic cancer.
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Affiliation(s)
- Suzanne Russo
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - John Ammori
- Department of Surgery, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Jennifer Eads
- Department of Medicine, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Jennifer Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA
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Rutter CE, Park HS, Corso CD, Lester-Coll NH, Mancini BR, Yeboa DN, Johung KL. Addition of radiotherapy to adjuvant chemotherapy is associated with improved overall survival in resected pancreatic adenocarcinoma: An analysis of the National Cancer Data Base. Cancer 2015; 121:4141-9. [PMID: 26280559 DOI: 10.1002/cncr.29652] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 07/20/2015] [Accepted: 08/03/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal treatment for resected pancreatic cancer is controversial because direct comparisons of adjuvant chemotherapy (CT) alone and chemotherapy and radiotherapy (CRT) are limited. This study assessed outcomes of CT versus CRT in a national cohort to provide a modern estimate of comparative effectiveness. METHODS Patients with pT1-3N0-1M0 pancreatic adenocarcinoma after pancreatectomy were identified in the National Cancer Data Base. Overall survival (OS) was compared for CT and CRT groups with Cox regression and propensity score matching. Subset analyses by clinicopathologic characteristics were performed. RESULTS This study identified 6165 patients treated with CT (n = 2334 or 38%) or CRT (n = 3831 or 62%). Most were classified as pT3 (72%), pN1 (67%), and status-post R0 resection (84%). For CRT patients, the median radiotherapy dose was 50.4 Gy. Compared with CT, CRT was associated with improved OS in a univariate analysis (median, 20.0 vs 22.3 months; at 5 years, 16.5% vs 19.6%; P < .001) and a multivariate analysis (hazard ratio [HR], 0.893; 95% confidence interval [CI], 0.837-0.953; P = .001). CRT remained associated with improved OS after propensity score matching (HR, 0.851; 95% CI, 0.793-0.913; P < .001). Subset analyses showed that CRT was associated with improved OS among patients with pT3 (HR, 0.892; 95% CI, 0.828-0.962; P = .003) or pN1 disease (HR, 0.856; 95% CI, 0.793-0.924; P < .001) and both R0 resection (HR, 0.901; 95% CI, 0.839-0.969; P = .005) and R1 resection (HR, 0.842; 95% CI, 0.722-0.983; P = .030). CONCLUSIONS CRT was independently associated with improved OS after the resection of pancreatic adenocarcinoma in a large national cohort and particularly among patients with R1 resection and pN1 disease. Well-designed randomized comparisons of CRT and CT are urgently needed.
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Affiliation(s)
- Charles E Rutter
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Henry S Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Christopher D Corso
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | | | - Brandon R Mancini
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Debra N Yeboa
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Kimberly L Johung
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
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Fathi A, Christians KK, George B, Ritch PS, Erickson BA, Tolat P, Johnston FM, Evans DB, Tsai S. Neoadjuvant therapy for localized pancreatic cancer: guiding principles. J Gastrointest Oncol 2015; 6:418-29. [PMID: 26261728 PMCID: PMC4502155 DOI: 10.3978/j.issn.2078-6891.2015.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 04/27/2015] [Indexed: 12/17/2022] Open
Abstract
The management of localized pancreatic cancer (PC) remains controversial. Historically, patients with localized disease have been treated with surgery followed by adjuvant therapy (surgery-first approach) under the assumption that surgical resection is necessary, even if not sufficient for cure. However, a surgery-first approach is associated with a median overall survival of only 22-24 months, suggesting that a large proportion of patients with localized PC have clinically occult metastatic disease. As a result, adjuvant therapy has been recommended for all patients with localized PC, but in actuality, it is often not received due to the high rates of perioperative complications associated with pancreatic resections. Recognizing that surgery may be necessary but usually not sufficient for cure, there has been growing interest in neoadjuvant treatment sequencing, which benefits patients with both localized and metastatic PC by ensuring the delivery of oncologic therapies which are commensurate with the stage of disease. For patients who have clinically occult metastatic disease, neoadjuvant therapy allows for the early delivery of systemic therapy and avoids the morbidity and mortality of a surgical resection which would provide no oncologic benefit. For patients with truly localized disease, neoadjuvant therapy ensures the delivery of all components of the multimodality treatment. This review details the rationale for a neoadjuvant approach to localized PC and provides specific recommendations for both pretreatment staging and treatment sequencing for patients with resectable and borderline resectable (BLR) disease.
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Gudjonsson B. Survival calculations. Surgery 2014; 156:1286. [PMID: 25444321 DOI: 10.1016/j.surg.2014.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 06/09/2014] [Indexed: 11/15/2022]
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Paniccia A, Edil BH, Schulick RD, Byers JT, Meguid C, Gajdos C, McCarter MD. Neoadjuvant FOLFIRINOX application in borderline resectable pancreatic adenocarcinoma: a retrospective cohort study. Medicine (Baltimore) 2014; 93:e198. [PMID: 25501072 PMCID: PMC4602784 DOI: 10.1097/md.0000000000000198] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
5-Fluorouracile, oxaliplatin, irinotecan, and leucovorin (FOLFIRINOX) has not been extensively used in the neoadjuvant setting because of concerns with safety and toxicity. We evaluated our institutional experience with neoadjuvant FOLFIRINOX in borderline resectable pancreatic adenocarcinoma (BRPAC). The primary endpoints were completion of therapy to surgery and negative resection margin (R0) rate. Patients with BRPAC treated with neoadjuvant FOLFIRINOX were retrospectively analyzed. Between August 2011 and September 2013, 20 patients with BRPAC treated with neoadjuvant FOLFIRINOX were identified. Most patients (88.8%) completed FOLFIRINOX therapy and underwent resection. Abutment of venous structures was identified in 13 cases (72.2%), while short segment portal vein encasement in 3 cases (16.6%) with concomitant arterial involvement in 3 cases (16.6%). Isolated superior mesenteric artery abutment was identified in 2 cases (11.2%). Patients received a median of 4 cycles of FOLFIRINOX. There was 1 case of progression. Vascular resection was performed in 9 cases (52.9%). Preoperative radiation therapy was used in 8 patients (44%). All patients underwent margin negative resection (R0). Histopathologic treatment response was evident in 10 cases (58.8%). Neoadjuvant FOLFIRINOX was generally safe and the expected toxicity did not prevent surgery allowing for a high rate of R0 resection.
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Affiliation(s)
- Alessandro Paniccia
- From the Division of Gastrointestinal, Tumor, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
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Abstract
The R1 rate and prognostic significance of microscopic margin involvement differ consistently between published series. This divergence results from a lack of consensus regarding various aspects of margin status assessment. Central to the controversies is the lack of clarity about what 'R1' exactly stands for. The current UICC definition--residual microscopic tumor--is possibly too general and invites divergent interpretations. Adherence to different diagnostic criteria for microscopic margin involvement and divergent terminology for the various margins of pancreatoduodenectomy specimens add to the confusion. Furthermore, recent studies demonstrated that the dissection technique and extent of tissue sampling influence the accuracy of margin assessment. Axial specimen slicing, extensive tissue sampling, and multicolored margin inking result in a significantly higher, more accurate R1 rate than when using traditional grossing techniques. Only when international consensus on these various aspects is reached will pathology data on margin involvement be reliable and can multicenter clinical trials produce compelling evidence that allows improved pancreatic cancer treatment.
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Affiliation(s)
- C S Verbeke
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institute, Clinical Pathology and Cytology, F42 , Karolinska University Hospital Huddinge, F42, 141 86, Stockholm, Sweden,
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Sabater L, Gómez-Mateo MDC, López-Sebastián J, Muñoz-Forner E, Morera-Ocón F, Cervantes A, Roselló S, Camps-Vilata B, Ferrández A, Ortega J. Implicaciones pronósticas del estudio estandarizado de los márgenes de resección en el cáncer de páncreas. Cir Esp 2014; 92:532-8. [DOI: 10.1016/j.ciresp.2013.07.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Revised: 07/10/2013] [Accepted: 07/12/2013] [Indexed: 10/25/2022]
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Gómez-Mateo MDC, Sabater-Ortí L, Ferrández-Izquierdo A. Pathology handling of pancreatoduodenectomy specimens: Approaches and controversies. World J Gastrointest Oncol 2014; 6:351-9. [PMID: 25232460 PMCID: PMC4163733 DOI: 10.4251/wjgo.v6.i9.351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 10/21/2013] [Accepted: 12/17/2013] [Indexed: 02/05/2023] Open
Abstract
Pancreatic cancer, with a 5% 5-year survival rate, is the fourth leading cause of cancer death in Western countries. Unfortunately, only 20% of all patients benefit from surgical treatment. The need to prolong survival has prompted pathologists to develop improved protocols to evaluate pancreatic specimens and their surgical margins. Hopefully, the new protocols will provide clinicians with more powerful prognostic indicators and accurate information to guide their therapeutic decisions. Despite the availability of several guidelines for the handling and pathology reporting of duodenopancreatectomy specimens and their continual updating by expert pathologists, there is no consensus on basic issues such as surgical margins or the definition of incomplete excision (R1) of pancreatic ductal adenocarcinoma. This article reviews the problems and controversies that dealing with duodenopancreatectomy specimens pose to pathologists, the various terms used to define resection margins or infiltration, and reports. After reviewing the literature, including previous guidelines and based on our own experience, we present our protocol for the pathology handling of duodenopancreatectomy specimens.
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Shin SH, Kim SC, Hong SM, Song KB, Lee JH, Park KM, Lee YJ. Can statistically determined prognostic factors predict the long-term survival of patients with pancreatic ductal adenocarcinoma following surgical resection?: Clinicopathological analysis of 82 long-term survivors. Pancreas 2014; 43:571-7. [PMID: 24681875 DOI: 10.1097/mpa.0000000000000063] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The objective of this study were to analyze and describe the clinicopathological characteristics of long-term pancreatic ductal adenocarcinoma survivors and to determine if statistically identified prognostic factors can be used to predict the actual survival. METHODS Between January 2000 and December 2007, 537 patients with resectable pancreatic ductal adenocarcinoma underwent surgical resection at a single institute. Medical records were retrospectively reviewed, and 9 patients were excluded. Of the remaining 528, patients who survived for more than 5 years were classified as long-term survivors. RESULTS The actual 5-year survival rate of all 528 included patients was 15.5% (82 patients; median follow-up period, 82.7 months). Fifty-eight patients (70.7%) were diagnosed with cancers located in the head of pancreas, and the median size was 2.5 cm (range, 0.8-12.0 cm). Three patients had focal involvement noted on the resected surfaces. Poorly differentiated carcinoma (9.8%), lymph node metastasis (32.9%), lymphovascular invasion (25.6%), and perineural invasion (48.8%) were detected. Fifty-five of the 82 long-term survivors whose clinicopathological characteristics included several dismal predictors survived for more than 5 years without recurrence. CONCLUSIONS The long-term survivors identified in this study did not meet the appropriate prognostic criteria. Therefore, there are limitations in the use of statistically determined prognostic factors for estimating in the long term.
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Affiliation(s)
- Sang Hyun Shin
- From the Departments of *Surgery and †Pathology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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Palta M, Willett C, Czito B. The Role of Intraoperative Radiation Therapy in Patients With Pancreatic Cancer. Semin Radiat Oncol 2014; 24:126-31. [DOI: 10.1016/j.semradonc.2013.11.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Yang C, Wu HS, Chen XL, Wang CY, Gou SM, Xiao J, He ZQ, Chen QJ, Li YF. Pylorus-preserving versus pylorus-resecting pancreaticoduodenectomy for periampullary and pancreatic carcinoma: a meta-analysis. PLoS One 2014; 9:e90316. [PMID: 24603478 PMCID: PMC3946060 DOI: 10.1371/journal.pone.0090316] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 01/28/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The aim of this meta-analysis was to compare the long-term survival, mortality, morbidity and the operation-related events in patients with periampullary and pancreatic carcinoma undergoing pylorus-preserving pancreaticoduodenectomy (PPPD) and pylorus-resecting pancreaticoduodenectomy (PRPD). METHOD A systematic search of literature databases (Cochrane Library, PubMed, EMBASE and Web of Science) was performed to identify studies. Outcome measures comparing PPPD versus PRPD for periampullary and pancreatic carcinoma were long-term survival, mortality, morbidity (overall morbidity, delayed gastric emptying [DGE], pancreatic fistula, wound infection, postoperative bleeding, biliary leakage, ascites and gastroenterostomy leakage) and operation related events (hospital stays, operating time, intraoperative blood loss and red blood cell transfusions). RESULTS Eight randomized controlled trials (RCTs) including 622 patients were identified and included in the analysis. Among these patients, it revealed no difference in long-term survival between the PPPD and PRPD groups (HR = 0.23, p = 0.11). There was a lower rate of DGE (RR = 2.35, p = 0.04, 95% CI, 1.06-5.21) with PRPD. Mortality, overall morbidity, pancreatic fistula, wound infection, postoperative bleeding, biliary leakage, ascites and gastroenterostomy leakage were not significantly different between the groups. PPPDs were performed more quickly than PRPDs (WMD = 53.25 minutes, p = 0.01, 95% CI, 12.53-93.97); and there was less estimated intraoperative blood loss (WMD = 365.21 ml, p = 0.006, 95% CI, 102.71-627.71) and fewer red blood cell transfusions (WMD = 0.29 U, p = 0.003, 95% CI, 0.10-0.48) in patients undergoing PPPD. The hospital stays showed no significant difference. CONCLUSIONS PPPD had advantages over PRPD in operating time, intraoperative blood loss and red blood cell transfusions, but had a significantly higher rate of DGE for periampullary and pancreatic carcinoma. PPPD and PRPD had comparable mortality and morbidity including pancreatic fistulas, wound infections, postoperative bleeding, biliary leakage, ascites and gastroenterostomy leakage. Our conclusions were limited by the available data. Further evaluations of high-quality RCTs are needed.
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Affiliation(s)
- Chong Yang
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - He-Shui Wu
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Xing-Lin Chen
- Key Laboratory of Geriatrics of Health Ministry, Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Chun-You Wang
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Shan-Miao Gou
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jun Xiao
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Zhi-Qiang He
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Qi-Jun Chen
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Yong-Feng Li
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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Binziad S, Salem AAS, Amira G, Mourad F, Ibrahim AK, Manim TMA. Impact of reconstruction methods and pathological factors on survival after pancreaticoduodenectomy. South Asian J Cancer 2014; 2:160-8. [PMID: 24455609 PMCID: PMC3889193 DOI: 10.4103/2278-330x.114145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Surgery remains the mainstay of therapy for pancreatic head (PH) and periampullary carcinoma (PC) and provides the only chance of cure. Improvements of surgical technique, increased surgical experience and advances in anesthesia, intensive care and parenteral nutrition have substantially decreased surgical complications and increased survival. We evaluate the effects of reconstruction type, complications and pathological factors on survival and quality of life. Materials and Methods: This is a prospective study to evaluate the impact of various reconstruction methods of the pancreatic remnant after pancreaticoduodenectomy and the pathological characteristics of PC patients over 3.5 years. Patient characteristics and descriptive analysis in the three variable methods either with or without stent were compared with Chi-square test. Multivariate analysis was performed with the logistic regression analysis test and multinomial logistic regression analysis test. Survival rate was analyzed by use Kaplan-Meier test. Results: Forty-one consecutive patients with PC were enrolled. There were 23 men (56.1%) and 18 women (43.9%), with a median age of 56 years (16 to 70 years). There were 24 cases of PH cancer, eight cases of PC, four cases of distal CBD cancer and five cases of duodenal carcinoma. Nine patients underwent duct-to-mucosa pancreatico jejunostomy (PJ), 17 patients underwent telescoping pancreatico jejunostomy (PJ) and 15 patients pancreaticogastrostomy (PG). The pancreatic duct was stented in 30 patients while in 11 patients, the duct was not stented. The PJ duct-to-mucosa caused significantly less leakage, but longer operative and reconstructive times. Telescoping PJ was associated with the shortest hospital stay. There were 5 postoperative mortalities, while postoperative morbidities included pancreatic fistula-6 patients, delayed gastric emptying in-11, GI fistula-3, wound infection-12, burst abdomen-6 and pulmonary infection-2. Factors that predisposed to development of pancreatic leakage included male gender, preoperative albumin < 30g/dl, pre-operative hemoglobin < 10g/dl and non PJ-duct to mucosa type of reconstruction. The ampullary cancers presented at an earlier stage and had a better prognosis than pancreatic cancer and cholangiocarcinoma. Early stage (I and II), negative surgical margin, well and moderate differentiation and absence of lymph node involvement significantly predicted for longer survival. Conclusions: PJ duct-to-mucosa anastomosis was safe, caused least pancreatic leakage and least blood loss compared with the other methods of reconstruction and was associated with early return back to home and prolonged disease free and overall survival.
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Affiliation(s)
- Salah Binziad
- Department of Surgical Oncology, Assiut University, Assiut, Egypt
| | - Ahmed A S Salem
- South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Gamal Amira
- National Cancer Institute, Cairo University, Giza, Egypt
| | - Farouk Mourad
- Department of General Surgery, Assiut University, Assiut, Egypt
| | - Ahmed K Ibrahim
- Department of Public Health and Community Medicine, Assiut, Egypt
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Kim PTW, Wei AC, Atenafu EG, Cavallucci D, Cleary SP, Moulton CA, Greig PD, Gallinger S, Serra S, McGilvray ID. Planned versus unplanned portal vein resections during pancreaticoduodenectomy for adenocarcinoma. Br J Surg 2013; 100:1349-56. [PMID: 23939847 DOI: 10.1002/bjs.9222] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND The management of portal vein (PV) involvement by pancreatic adenocarcinoma during pancreaticoduodenectomy (PD) is controversial. The aim of this study was to compare the outcomes of unplanned and planned PV resections as part of PD. METHODS An analysis of PD over 11 years was performed. Patients who had undergone PV resection (PV-PD) were identified, and categorized into those who had undergone planned or unplanned resection. Postoperative and oncological outcomes were compared. RESULTS Of 249 patients who underwent PD for pancreatic adenocarcinoma, 66 (26·5 per cent) had PV-PD, including 27 (41 per cent) planned and 39 (59 per cent) unplanned PV resections. Twenty-five of 27 planned PV resections were circumferential PV-PD, whereas 25 of 39 unplanned PV resections were partial PV-PD. Planned PV resections were performed in slightly younger patients (mean(s.d.) 60(9) versus 65(10) years; P = 0·031), and associated with longer operating times (mean(s.d.) 602(131) versus 458(83) min; P < 0·001) and more major complications (26 versus 5 per cent; P = 0·026). Planned PV resections were associated with a lower rate of positive margins (4 versus 44 per cent; P < 0·001) despite being carried out for larger tumours (mean(s.d.) 3·9(1·4) versus 2·9(1·0) cm; P = 0·002). There was no difference in survival between the two groups (P = 0·998). On multivariable analysis, margin status was a significant predictor of survival. CONCLUSION Although planned PV resections for pancreatic adenocarcinoma were associated with higher rates of postoperative morbidity than unplanned resections, R0 resection rates were better.
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Affiliation(s)
- P T W Kim
- Hepatopancreatobiliary Surgical Oncology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Walker AJ, Alcorn S, Narang A, Nugent K, Wild AT, Herman JM, Tran PT. Radiosensitizers in pancreatic cancer--preclinical and clinical exploits with molecularly targeted agents. Curr Probl Cancer 2013; 37:301-12. [PMID: 24331186 PMCID: PMC3868005 DOI: 10.1016/j.currproblcancer.2013.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
There has been an explosion in the number of molecularly targeted agents engineered to inhibit specific molecular pathways driving the tumorigenic phenotype in cancer cells. Some of these molecularly targeted agents have demonstrated robust clinical effects, but few result in meaningful durable responses. Therapeutic radiation is used to treat a majority of cancer patients with recent technologic and pharmacologic enhancements, leading to improvements in the therapeutic ratio for cancer care. Radiotherapy has a very specific role in select cases of postoperative and locally advanced pancreatic cancer patients, but control of metastatic disease still appears to be the major limiting factor behind improvements in cure. Recent rapid autopsy pathologic findings suggest a sub-group of advanced pancreatic cancer patients where death is caused from local disease progression and who would thus benefit from improved local control. One promising approach is to combine molecularly targeted agents with radiotherapy to improve tumor response rates and likelihood of durable local control. We review suggested recommendations on the investigation of molecularly targeted agents as radiosensitizers from preclinical studies to implementation in phase I–II clinical trials. We then discuss a select set of molecularly targeted therapies that we believe show promise as radiosensitizers in the treatment of pancreatic cancer.
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Affiliation(s)
- Amanda J. Walker
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231
| | - Sara Alcorn
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231
| | - Amol Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231
| | - Katriana Nugent
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231
| | - Aaron T. Wild
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21231
| | - Joseph M. Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Oncology, and Surgery, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway Street Baltimore, MD 21231, , Phone (410) 502-3823, Fax (410) 502-1419
| | - Phuoc T. Tran
- Department of Radiation Oncology and Molecular Radiation Sciences, Oncology, and Urology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway Street Baltimore, MD 21231, , Phone (410) 614-3880, Fax (410) 502-1419
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Wolfgang CL, Herman JM, Laheru DA, Klein AP, Erdek MA, Fishman EK, Hruban RH. Recent progress in pancreatic cancer. CA Cancer J Clin 2013; 63:318-48. [PMID: 23856911 PMCID: PMC3769458 DOI: 10.3322/caac.21190] [Citation(s) in RCA: 643] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 03/22/2013] [Accepted: 03/22/2013] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is currently one of the deadliest of the solid malignancies. However, surgery to resect neoplasms of the pancreas is safer and less invasive than ever, novel drug combinations have been shown to improve survival, advances in radiation therapy have resulted in less toxicity, and enormous strides have been made in the understanding of the fundamental genetics of pancreatic cancer. These advances provide hope but they also increase the complexity of caring for patients. It is clear that multidisciplinary care that provides comprehensive and coordinated evaluation and treatment is the most effective way to manage patients with pancreatic cancer.
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Affiliation(s)
- Christopher L. Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Joseph M. Herman
- Department of Radiation Oncology & Molecular Radiation Sciences, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Daniel A. Laheru
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Alison P. Klein
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Epidemiology, the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael A. Erdek
- Department of Anesthesiology and Critical Care Medicine, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Elliot K. Fishman
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Ralph H. Hruban
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
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Tinchon C, Hubmann E, Pichler A, Keil F, Pichler M, Rabl H, Uggowitzer M, Jilek K, Leitner G, Bauernhofer T. Safety and efficacy of neoadjuvant FOLFIRINOX treatment in a series of patients with borderline resectable pancreatic ductal adenocarcinoma. Acta Oncol 2013; 52:1231-3. [PMID: 23445338 DOI: 10.3109/0284186x.2013.771821] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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