Definitive chemoradiation therapy with capecitabine in locally advanced pancreatic cancer

A phase 1 dual-dose escalation study of radiation and nab-paclitaxel in patients with unresectable and borderline resectable pancreatic cancer

BACKGROUND

This phase 1 dual dose-escalation study aimed to evaluate the safety, feasibility, and toxicity profile of combining dose-escalated radiation therapy with high-dose nab-paclitaxel in patients with unresectable or borderline resectable pancreatic cancer.

METHODS AND MATERIALS

Twenty-one evaluable patients were enrolled and allocated three radiation dose levels, 55 Gy, 57.5 Gy, and 60 Gy, administered over 5 weeks in 25 fractions. Concurrent nab-paclitaxel was given weekly at a dose of 125 mg/m2. Radiation dose escalation was guided by a time-to-event continual reassessment method. Toxicities were classified according to CTCAE v4.0, with dose-limiting toxicities (DLT) defined as grade 3 or higher gastrointestinal events or substantial decline in performance status. Surgical resection was pursued in patients achieving sufficient tumor downstaging.

RESULTS

Hematologic toxicities were the most common grade ≥3 adverse events occurring in 76.2% of patients. Nonhematologic toxicities were less frequent (57.1%). Two grade 3 gastrointestinal DLT cases occurred at dose levels 57.5 Gy and 60 Gy. The maximum tolerated dose was 60 Gy with a probability of DLT of 0.155 at this dose. Surgical resection with negative margins was achieved in 33.3% of patients, including all borderline resectable cases and 22.2% of initially unresectable cases. The median overall survival and time to local progression from the start of radiation therapy were 22.3 months and 20.3 months, respectively.

CONCLUSIONS

This study demonstrates the feasibility and safety of combining dose-escalated radiation with high-dose nab-paclitaxel in locally advanced pancreatic cancer. The regimen is associated with manageable toxicity and promising local control and survival.

Application of preoperative three-dimensional model design in radioactive particle implantation for advanced pancreatic cancer

Objective

This study aimed to investigate the application of preoperative three-dimensional model design in radioactive particle implantation for advanced pancreatic cancer, and accordingly analyze the effect of particle implantation in the treatment of advanced pancreatic cancer.

Methods

The clinical data of 63 patients with advanced pancreatic cancer treated with particle implantation from January 2009 to June 2015 in the General Hospital of Chinese PLA were retrospectively analyzed. The implantation design was conducted using the FitMe three-dimensional model reconstruction software for all patients before the operation to explore the significance of preoperative three-dimensional model design in guiding operation. These data were compared with the general data, postoperative recovery, and follow-ups of patients with advanced pancreatic cancer, who underwent conservative treatment at the same time period, in order to explore the effect of particle implantation in the treatment of advanced pancreatic cancer.

Results

In the 63 patients with advanced pancreatic cancer who underwent particle implantation, the average number of implanted particles was 53.4±18.7. Gastroparesis occurred in 17 patients and pancreatic fistula occurred in 13 patients after the operation, and no perioperative death occurred.

Follow-up results

In the particle group, the relief rate of abdominal pain was 90.9%, the 1-month, 6-month, 1-year, and 2-year survival rates were 100%, 58.7%, 22.4%, and 9%, respectively, and median survival time was 10.4±0.7 months, which were significantly higher than patients in the control group (P<0.05), especially in patients with stage III pancreatic cancer.

Conclusion

For patients with advanced pancreatic cancer who could not undergo radical resection, radioactive particle implantation is an effective treatment, while the use of a preoperative three-dimensional model design for operation planning can maximize the effect of radioactive particles.

Concurrent radiotherapy with oral fluoropyrimidine versus gemcitabine in locally advanced pancreatic cancer: a systematic review and meta-analysis

Background

Gemcitabine (GEM) is the most widely utilized systemic agent in combination with radiation therapy (RT) for treating locally advanced pancreatic cancer (LAPC) in the concurrent setting. Despite recent interest in using two novel oral fluoropyrimidines (FUs), capecitabine and S-1, in this setting, there is a lack of randomized controlled trials (RCTs) to support this approach.

Methods

Trials published between 1994 and 2014 were identified by an electronic search of public databases (Medline, Embase, and the Cochrane Library). All prospective studies were independently identified by two authors for inclusion. Demographic data, treatment response, objective response rate (ORR), progression-free and overall survival (PFS and OS, respectively), and toxicities were extracted and analyzed using comprehensive meta-analysis software (version 2.0).

Results

Twenty-three cohorts with 843 patients were included: 497 patients were treated with GEM and 346 patients were treated with oral FU. Pooled OS was significantly higher at 1 and 2 years for S-1 plus RT than for GEM plus RT (relative risk [RR] 1.27; 95% confidence interval [CI], 1.00–1.65; P=0.03; and RR 1.75; 95% CI, 1.18–2.60, P=0.002, respectively), while 1-year PFS and ORR were not significantly different between S-1 and GEM-based chemoradiotherapy (P=0.37 and P=0.06, respectively). Additionally, comparable efficacy was found between capecitabine and GEM-based chemoradiotherapy in terms of OS, PFS, and ORR. As for grade 3 and 4 acute toxicity, oral FU plus RT significantly reduced the risk of developing hematologic toxicities, nausea, and vomiting when compared to GEM plus RT (P<0.001).

Conclusions

Oral FU plus RT may be a safe and feasible regimen for patients with LAPC, with similar efficacy and low rate of toxicities compared with GEM plus RT. Our findings support the need to compare S-1 with GEM in the concurrent setting in large prospective RCTs due to its potential survival benefits.

Definitive concurrent chemoradiotherapy in locally advanced pancreatic cancer

Purpose

Survival outcome of locally advanced pancreatic cancer has been poor and little is known about prognostic factors of the disease, especially in locally advanced cases treated with concurrent chemoradiation. This study was to analyze overall survival and prognostic factors of patients treated with concurrent chemoradiotherapy (CCRT) in locally advanced pancreatic cancer.

Materials and Methods

Medical records of 34 patients diagnosed with unresectable pancreatic cancer and treated with definitive CCRT, from December 2003 to December 2012, were reviewed. Median prescribed radiation dose was 50.4 Gy (range, 41.4 to 55.8 Gy), once daily, five times per week, 1.8 to 3 Gy per fraction.

Results

With a mean follow-up of 10 months (range, 0 to 49 months), median overall survival was 9 months. The 1- and 2-year survival rates were 40% and 10%, respectively. Median and mean time to progression were 5 and 7 months, respectively. Prognostic parameters related to overall survival were post-CCRT CA19-9 (p = 0.02), the Eastern Cooperative Oncology Group (ECOG) status (p < 0.01), and radiation dose (p = 0.04) according to univariate analysis. In multivariate analysis, post-CCRT CA19-9 value below 180 U/mL and ECOG status 0 or 1 were statistically significant independent prognostic factors associated with improved overall survival (p < 0.01 and p = 0.02, respectively).

Conclusion

Overall treatment results in locally advanced pancreatic cancer are relatively poor and few improvements have been accomplished in the past decades. Post-treatment CA19-9 below 180 U/mL and ECOG performance status 0 and 1 were significantly associated with an improved overall survival.

Treatment options for advanced pancreatic cancer: a review

Advanced pancreatic adenocarcinoma historically has a poor prognosis and the mortality rate has remained unchanged for over a decade. Common treatment options for patients with advanced pancreatic cancer include chemoradiation and/or chemotherapy. Single-agent gemcitabine has been considered the standard of care since 1997. Recently published findings indicate that the oxaliplatin, irinotecan, fluorouracil and leucovorin (FOLFIRINOX) treatment regimen significantly improves overall survival compared with gemcitabine. Research has shifted to focus on understanding the causes the resistance of pancreatic cancer to chemotherapy and potential methods to overcome it. This review will focus on the current treatment options, the evolution of targeted therapy, novel agents on the horizon and potential options to ameliorate chemoresistance.

Safety and efficacy of adjuvant chemoradiation therapy with capecitabine after resection of pancreatic ductal adenocarcinoma: a retrospective review

PURPOSE

To evaluate clinical outcomes and safety of adjuvant chemoradiation therapy (CRT) with capecitabine after resection of pancreatic adenocarcinoma at a single institution.

PATIENTS AND METHODS

A retrospective analysis of patients undergoing adjuvant CRT with capecitabine after resection of pancreatic ductal adenocarcinoma between 2004 and 2007 yielded a total of 55 patients. Capecitabine was administered at 850 mg/m(2) twice daily every day per week radiotherapy (45 Gy in 25 fractions) over the 5 weeks. Sixteen percent of patients (N=9) went on to receive gemcitabine.

RESULTS

Of 55 patients, 42 had curative (R0) resection and 13 had incomplete resection (R1). Median overall survival (OS) and progression free survival were 18.3 and 8.0 months for all patients, respectively. Patients receiving additional gemcitabine after adjuvant CRT with capecitabine showed better OS and progression free survival than those not receiving additional gemcitabine (P<0.05). In multivariate analysis, lymphovascular invasion (present vs. absent) and addition gemcitabine therapy (yes vs. no) were significant independent prognostic factors for OS (P<0.05). Local recurrence was observed in 10 patients, and distant recurrence in 26 patients, synchronously accounting for 6 recurrences. Ten patients (18.2%) had severe grade 3 toxicities.

CONCLUSIONS

Capecitabine-based CRT after resection of pancreatic adenocarcinoma showed favorable outcomes and tolerable toxicity profiles.