Novel Indications for Surgical Resection of Metachronous Lung Metastases From Pancreatic Cancer After Curative Resection

Patterns, timing and predictors of recurrence following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: an international multicentre retrospective cohort study

BACKGROUND

Most patients undergoing pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) develop recurrence. No previous studies have investigated predictors of local-only recurrence following PD for PDAC. Our study aimed to determine timing, pattern and predictors of any-site and local-only recurrence following PD for PDAC.

METHODS

Patients who underwent PD for PDAC between June 2012 and May 2015 (29 centres, eight countries) were included. The primary outcome was recurrence pattern (none, local-only, distant-only or mixed local/distant). Data were collected on demographics, comorbidities, investigations, operation details, complications, histology, adjuvant therapies, recurrence and survival. Univariable tests and regression analysis investigated factors associated with any-site and local-only recurrence.

RESULTS

Of 866 patients, 573 (66 %) developed recurrence: 170 (20 %) developed local-only recurrence, 164 (19 %) developed mixed local/distant recurrence, and 239 (28 %) developed distant-only recurrence. Local-only or lung-only recurrence had a more favourable prognosis than other recurrence patterns. Predictors of any-site recurrence were preoperative biliary stenting, venous resection and poorly-differentiated, node-positive tumours. Predictors of local-only recurrence were preoperative radiological lymphadenopathy, well-differentiated tumours, fewer than 15 resected lymph nodes and intraoperative blood transfusion.

DISCUSSION

Ensuring radical resection and avoiding intraoperative blood transfusion may reduce the risk of local-only recurrence following PD for PDAC.

The role of pulmonary metastasectomy in patients suffering pancreatic ductal adenocarcinoma with lung metastases: a systematic review and meta-analysis

Background

Because of the high rate of recurrence, the prognosis of patients with pancreatic ductal adenocarcinoma (PDAC) is still very poor despite underwent pancreatectomy and adjuvant chemotherapy. A few reports have suggested the feasibility and efficacy of surgical resection for pulmonary metastases of PDAC. However, the role of metastasectomy of recurrent PDAC remains controversial. The aim of this study is to evaluate the benefits of pulmonary metastasectomy in PDAC patients with lung metastases.

Methods

We searched the PubMed, Embase, and Cochrane Library databases and extracted the hazard ratio (HR) with 95% confidence interval (CI) from eligible studies. Pooled HR with 95% CI were used to reveal the association between pulmonary metastasectomy and survival.

Results

The meta-analysis encompassed data from nine studies, comprising 467 patients suffered PDAC with lung metastasis. The results (the pooled HR: 0.637, 95% CI: 0.531-0.764, I 2 = 61.5%, p value = 0.008) indicated that patients with lung metastasis who underwent pulmonary metastasectomy seemed to have better survival when compared with patients who underwent only chemotherapy. The robustness of these pooled results was verified by our subgroup analysis and sensitivity analysis. Moreover, the varying sample sizes among studies contribute to the heterogeneity in the pooled hazard ratio (HR) for survival, as indicated by the meta-regression analysis (p value = 0.045).

Conclusion

Pulmonary metastasectomy could prolong the survival in patients with lung metastases from PDAC. However, the present study is based on a relatively small number of patients and may include a selection bias. More multi-institutional prospective study is needed to evaluated the clinical value of pulmonary metastasectomy.

Meta-analysis of survival after pulmonary resection for isolated metachronous pancreatic cancer metastasis: a promising, albeit infrequent, approach

BACKGROUND

To evaluate survival outcomes of pulmonary resection for isolated metachronous pancreatic cancer metastasis.

METHODS

A systematic search of electronic data sources and reference lists were conducted. Proportion meta-analysis model was constructed to quantify 1- to 5-year survival after pulmonary resection for isolated metachronous pancreatic cancer metastasis. Random-effects modelling was applied to calculate pooled outcome data.

RESULTS

Twenty-four retrospective studies were included reporting a total of 168 patients who underwent pulmonary resection for isolated pancreatic cancer metastasis. The nature of the index pancreatic surgery included 65% pancreaticoduodenectomies, 17.5% distal pancreatectomies, 0.5% total pancreatectomy, and 17% unspecified. Adjuvant chemotherapy was given to 88% of the patients. The median disease-free interval was 35 (8-96) months. The type of pulmonary resection included 54% wedge resections, 26% lobectomies, 4% segmentectomies, 1% pneumonectomies, and 15% unspecified. Pulmonary resection was associated with 1-year survival of 91.1% (95% CI 86.6%-95.5%), 2-year survival of 77.5% (95% CI 68.9%-86.0%), 3-year survival of 65.0% (95% CI 50.7%-79.3%), 4-year survival of 52.0% (95% CI 37.2%-66.9%), and 5-year survival of 37.0% (95% CI 25.0%-49.1%).

CONCLUSION

Pulmonary resection for isolated pancreatic cancer metastasis is associated with acceptable overall patient survival. We recommend selective pulmonary resection for isolated pulmonary metastasis from pancreatic cancer. Our findings may encourage conduction of better-quality studies in this context to help establishment of definitive treatment strategies.

Surgery for Oligometastatic Pancreatic Cancer: Defining Biologic Resectability

Pancreatic ductal adenocarcinoma (PDAC) is most often metastatic at diagnosis. As systemic therapy continues to improve alongside advanced surgical techniques, the focus has shifted toward defining biologic, rather than technical, resectability. Several centers have reported metastasectomy for oligometastatic PDAC, yet the indications and potential benefits remain unclear. In this review, we attempt to define oligometastatic disease in PDAC and to explore the rationale for metastasectomy. We evaluate the existing evidence for metastasectomy in liver, peritoneum, and lung individually, assessing the safety and oncologic outcomes for each. Furthermore, we explore contemporary biomarkers of biological resectability in oligometastatic PDAC, including radiographic findings, biochemical markers (such as CA 19-9 and CEA), inflammatory markers (including neutrophil-to-lymphocyte ratio, C-reactive protein, and scoring indices), and liquid biopsy techniques. With careful consideration of existing data, we explore the concept of biologic resectability in guiding patient selection for metastasectomy in PDAC.

Metastatic pulmonary adenocarcinoma after 20 years of primary pancreatic adenocarcinoma resection: A case report and literature review

Introduction

Recurrency of Pancreatic adenocarcinoma after resection can be as high as 85%. Most of the recurrences happen within two years of pancreatic resection and may be local or present as a metastatic disease.

Clinical presentation

Herein, we report a patient who presented with metastatic pulmonary adenocarcinoma after 20 years of curative resection of pancreatic adenocarcinoma. Histopathology of the pulmonary mass confirms the diagnosis as a metastatic adenocarcinoma of gastrointestinal origin.

Conclusion

Despite the length of the disease-free period, lung metastasis of pancreatic cancer is the most likely diagnosis according to the clinical course, histopathology and biochemical tumor marker. Tumor marker Ca19-9 is very sensitive and reliable test to detect recurrency of pancreatic cancer even if the imaging modalities cannot detect the tumor.

Evolving pancreatic cancer treatment: From diagnosis to healthcare management

The prognosis of pancreatic ductal adenocarcinoma is still the worst among solid tumors. In this review, a panel of experts addressed the main unanswered questions about the clinical management of this disease, with the aim of providing practical decision support for physicians. On the basis of the evidence available from the literature, the main topics concerning pancreatic cancer are discussed: the diagnosis, as the need for a pathological characterization and the role for germ-line and somatic molecular profiling; the therapeutic management of resectable disease, as the role of upfront surgery or neoadjuvant chemotherapy, the post-operative restaging and the optimal timing foradjuvant chemotherapy, the management of the borderline resectable and locally advanced disease; the metastatic disease and the role of surgery for the management of patients with isolated metastasis and the use of biomarkers of metastatic potential; the role of supportive care and the healthcare management of pancreatic ductal adenocarcinoma.

Lorlatinib Induces Durable Disease Stabilization in a Pancreatic Cancer Patient with a ROS1 p.L1950F Mutation: Case Report

INTRODUCTION

The prognosis of pancreatic cancer has improved only modestly in recent years. This is partly due to the lack of development in precision oncology including immune oncology in this entity. Rearrangements of the proto-oncogene tyrosine protein kinase ROS1 gene represent driver alterations found especially in lung cancer. Tyrosine kinase inhibitors (TKI) with activity against ROS1 including lorlatinib substantially improved the outcome of this patient population. Anecdotal evidence reports treatment of pancreatic cancer harboring ROS1 fusions with ROS1 TKI, but data concerning treatment of patients with ROS1 point mutations are lacking.

CASE PRESENTATION

This case describes a pancreatic cancer patient harboring a ROS1 point mutation that occurred without an underlying ROS1 rearrangement and thus not in the resistance situation. The heavily pretreated patient showed a strong decrease of the tumor biomarkers (CA19-9 and CEA) and radiologically a durable stable disease to the targeted treatment with lorlatinib, thereby achieving a progression-free survival of 12 months.

CONCLUSION

Our data are the first to show a clinical benefit from targeted treatment with ROS1 TKI in a cancer patient with a thus far undescribed ROS1 point mutation without a concomitant ROS1 rearrangement. Furthermore, they indicate that ROS1 could be an oncogenic driver in pancreatic cancer. This subgroup could be eligible for targeted treatments, which may contribute to the urgently needed improvement in patient outcome.

Significance of pulmonary resection in patients with metachronous pulmonary metastasis from pancreatic ductal adenocarcinoma: a retrospective cohort study

Background

Pulmonary metastases from pancreatic ductal adenocarcinoma (PDAC) are relatively rare. Systemic chemotherapy is the first choice of treatment in patients with distant metastases, and the role of metastasectomy is controversial. The aim of the present study was to evaluate the outcome of patients with pulmonary metastases after resection of PDAC and the indications for metastasectomy.

Methods

We retrospectively analysed patients with pulmonary metastases as the first recurrence after resection of primary PDAC between January 2006 and December 2018. Clinical data were obtained from the patients’ medical records. Relapse-free survival (RFS) and overall survival (OS) were analysed using the Kaplan–Meier method, and statistical significance was evaluated by the log-rank test.

Results

Of the 417 patients with resected PDACs, 24 (7.9%) had pulmonary metastases. Six patients (25.0%) underwent pulmonary resection and 18 (75.0%) received systemic chemotherapy and best supportive care. There were no major complications requiring therapeutic intervention after pulmonary resection. The median RFS was 24.0 months (95% CI 10.8–37.2), and the 1-, 3-, and 5-year RFS rates were 66.7%, 33.3%, and 4.2%, respectively. The median OS was 50.0 months (95% CI 15.9–84.1), and the 1-, 3-, and 5-year OS rates were 95.8%, 70.3%, and 46.4%, respectively. All patients with resected pulmonary metastases were alive at the end of the study, whereas the median OS of the patients who did not undergo resection was 37.0 months (95% CI 34.4–39.6). Therefore, patients with resected pulmonary metastases had a significantly better prognosis (p = 0.008).

Conclusions

Pulmonary resection may improve the prognosis in selected patients with pulmonary metastases from PDAC. However, the present study is based on a small number of patients and may include a selection bias; therefore, a multi-institutional prospective study is needed to clarify the indications for pulmonary resection.

Locoregional Treatment of Metastatic Pancreatic Cancer Utilizing Resection, Ablation and Embolization: A Systematic Review

Simple Summary

Metastatic pancreatic ductal adenocarcinoma (mPDAC) has a dismal prognosis. In selected patients with limited metastatic disease, locoregional therapy, in addition to systemic chemotherapy, may improve survival. This systematic review sought to examine current evidence on the value of additional locoregional treatment, including resection, ablation and embolization, in patients with hepatic or pulmonary mPDAC. The results, although liable to substantial bias, demonstrated superior survival from metastatic diagnosis or treatment in a subset of patients after radical-intent local primary and metastatic treatment (hepatic mPDAC 7.8–19 months; pulmonary mPDAC 22.8–47 months) compared to chemotherapy or best supportive care (hepatic mPDAC 4.3–7.6 months; pulmonary mPDAC 11.8 months). However, as a consequence of the bias, definitive conclusions regarding the seemingly beneficial effect of locoregional treatment cannot be endorsed. Randomized controlled trials with strictly selected oligometastatic PDAC patients are required to deduce final recommendations on this notion.

Abstract

The prognosis of metastatic pancreatic ductal adenocarcinoma (mPDAC) remains universally poor, requiring new and innovative treatment approaches. In a subset of oligometastatic PDAC patients, locoregional therapy, in addition to systemic chemotherapy, may improve survival. The aim of this systematic review was to explore and evaluate the current evidence on locoregional treatments for mPDAC. A systematic literature search was conducted on locoregional techniques, including resection, ablation and embolization, for mPDAC with a focus on hepatic and pulmonary metastases. A total of 59 studies were identified, including 63,453 patients. Although subject to significant bias, radical-intent local therapy for both the primary and metastatic sites was associated with a superior median overall survival from metastatic diagnosis or treatment (hepatic mPDAC 7.8–19 months; pulmonary mPDAC 22.8–47 months) compared to control groups receiving chemotherapy or best supportive care (hepatic mPDAC 4.3–7.6 months; pulmonary mPDAC 11.8 months). To recruit patients that may benefit from these local treatments, selection appears essential. Most significant is the upfront possibility of local radical pancreatic and metastatic treatment. In addition, a patient’s response to neoadjuvant systemic chemotherapy, performance status, metastatic disease load and, to a lesser degree, histological differentiation grade and tumor marker CA19-9 serum levels, are powerful prognostic factors that help identify eligible subjects. Although the exact additive value of locoregional treatments for mPDAC patients cannot be distillated from the results, locoregional primary pancreatic and metastatic treatment seems beneficial for a highly selected group of oligometastatic PDAC patients. For definite recommendations, well-designed prospective randomized controlled trials with strict in- and exclusion criteria are needed to validate these results.

CT features of lung metastases from pancreatic adenocarcinoma: Correlation with histopathologic findings

PURPOSE

The purpose of this study was to evaluate the prevalence of an atypical, alveolar presentation of pulmonary metastases from pancreatic adenocarcinoma (PDAC) on computed tomography (CT) and to correlate CT features with those obtained at histopathologic analysis.

MATERIAL AND METHODS

A total of 76 patients with lung metastases from PDAC over a 10-year period (2009-2019) in a French university hospital were retrospectively included. There were 34 men and 42 women with a mean age of 67.6±11.3 (SD) years (range: 38-89 years). CT features of PDAC were classified according to their presentations as usual metastatic pattern or atypical alveolar pattern; the atypical alveolar pattern corresponding to either ground glass nodules or opacities, solid nodules with a halo sign, "air-space" nodules with air bronchogram, or parenchymal consolidation. Imaging-histopathologic correlation was performed when tissue samples were available.

RESULTS

Pulmonary metastases were synchronous in 36 patients (36/76; 47%) and metachronous in 40 patients (40/76; 53%). A predominant alveolar presentation on CT was observed in 17 patients (17/76, 22%). Nodules with halo sign were the predominant alveolar pattern in 7 patients (7/17; 41%), air-space nodules were predominant in 4 patients (4/17; 24%) whereas pure ground glass nodules and consolidations were observed as predominant features in 3 patients (3/17; 18%) each. For 5 patients who had histopathological confirmation, alveolar metastases of PDAC were characterized by columnar tumor cells lining the alveolar wall, which was not seen in other radiological presentations, whereas there were no differences regarding mucin secretion between pulmonary metastases with alveolar presentation and those with typical pattern.

CONCLUSIONS

Lung metastases from PDAC may present with a so-called "alveolar" pattern on CT. This misleading CT features is found in 22% of patients with lung metastases from PDAC and is due to lepidic growth of the metastatic cells.

Metastases or primary recurrence to the lung is related to improved survival of pancreatic cancer as compared to other sites of dissemination. Results of a systematic review with meta-analysis

There are demonstrations that the prognosis of patients with isolated pulmonary dissemination of pancreatic cancer is more favorable than that of patients with other patterns of disease progression. The aim of this systematic review with meta-analysis was to evaluate the oncological outcomes of pulmonary vs. non-pulmonary metastasis of patients with pancreatic cancer. A total of 11 916 patients with secondary spread of pancreatic cancer were included from 15 primary reports. In the setting of single-organ disease dissemination, the lung demonstrated a significant survival advantage over hepatic, locoregional, or peritoneal localization. In particular, patients who recurred in the lung after pancreatectomy, showed a significant survival benefit as compared to those patients with hepatic and locoregional relapse in terms of disease-free survival, survival after recurrence and overall survival.

[Surgery for isolated local recurrence and metachronous oligometastasis in pancreatic cancer]

BACKGROUND

Most patients with pancreatic cancer suffer a relapse, which occurs either locally or systemically in the sense of liver and the lung metastases. Surgery for pancreatic cancer has become more radical due to the increased use of multimodal treatment concepts; however, the role of surgery in cases of recurrence remains controversial.

OBJECTIVE

This review summarizes the surgical treatment options for isolated local recurrence and metachronous oligometastatic pancreatic cancer.

MATERIAL AND METHODS

A selective literature search was carried out and the current evidence for surgical treatment is summarized.

RESULTS

There are currently no randomized studies on surgery for metastatic pancreatic cancer. Currently available data, however, show that after surgery long-term survival of up to 32-47 months after metastasectomy can be achieved, especially in patients with local recurrence or isolated pulmonary metastases with low morbidity and mortality. Individualized treatment concepts including surgical resection after initial systemic therapy seem promising even for liver metastases. The greatest survival benefits are consistently shown for all localizations in patients with a long as possible disease-free interval after the first operation.

CONCLUSION

The treatment of isolated local recurrence or metachronous oligometastatic pancreatic cancer is an interdisciplinary challenge that should be performed in specialized pancreatic treatment centers only. Surgical resection embedded in a multimodal treatment concept can be meaningful in selected cases.

Initial pulmonary metastasis after pancreatectomy for pancreatic ductal adenocarcinoma

Patients who undergo pancreatectomy for pancreatic ductal adenocarcinoma (PDA) develop relatively early recurrence, but pulmonary metastasis from PDA is rare. Between January 2008 and December 2016, a total of 120 consecutive patients underwent pancreatectomy for primary PDA at Osaka Medical College Hospital. Among these, 13 patients developed pulmonary metastasis and 6 patients underwent pulmonary metastasectomy. Among these patients, the median disease-free survival following initial pancreatic surgery was 26.1 months, and the median overall survival (OS) interval was 39 months. On the other hand, seven patients did not undergo pulmonary resection. The median OS interval of these patients was 33 months. The 1-, 3-, and 5-year OS rates were 100%, 80%, and 60%, respectively, for patients who underwent pulmonary metastasectomy and 100.0%, 42.8%, and 0%, respectively, for those who did not undergo the procedure. Our experience has shown that surgical resection may lengthen the survival time of patients who tolerate surgery.

Isolated pulmonary recurrence after resection of pancreatic cancer: the effect of patient factors and treatment modalities on survival

BACKGROUND

The literature suggests favorable survival for patients with isolated pulmonary recurrence after resection of pancreatic ductal adenocarcinoma (PDAC) as compared to other recurrence patterns. Within this cohort, it remains unclear what factors are associated with improved survival.

METHODS

Patients who developed pulmonary recurrence after pancreatectomy were selected from a prospective database. Predictors for post-recurrence survival (PRS) were analyzed using a multivariable Cox regression model.

RESULTS

Ninety-six patients were included. Median recurrence-free survival (RFS), PRS and overall survival (OS) were 16.3, 18.8 and 39.6 months, respectively. Further systemic treatment and/or metastasectomy (n = 64, 67%) was associated with significantly improved PRS and OS when compared to best supportive care (n = 35, 22%) (26.3 vs. 5.3 and 48.1 vs. 18.4, respectively; both P < 0.001). Patients who were able to undergo metastasectomy (n = 19) achieved a PRS and OS of 35.0 and 68.9 months, respectively. More than 5 pulmonary lesions, symptoms and CA 19-9 ≥100 U/mL at time of recurrence were predictive of decreased PRS. A recurrence-free interval of >16 months and treatment for recurrence were independently associated with improved PRS.

CONCLUSIONS

Isolated pulmonary recurrence occurs in 13% of patients with recurrent PDAC and is associated with a median OS of 40 months. Aggressive treatment in highly selected patients was correlated with improved survival.

Oligometastatic Disease in Pancreatic Cancer - How to Proceed?

BACKGROUND

Pancreatic cancer is a highly aggressive malignancy and will become the second leading cause of cancer-related death in the USA and also in Germany by 2030. Furthermore, the majority of patients with pancreatic ductal adenocarcinoma (PDAC) will present with distant metastases, limiting surgical management in this population as there is little evidence available to support surgical or ablative treatment options for advanced-stage disease. However, highly selected patients suffering from synchronous and metachronous oligometastatic PDAC may potentially benefit from a surgical resection with an acceptable morbidity.

METHODS

This review summarizes and discusses the current literature on the management of oligometastatic disease regarding PDAC, focusing on para-aortic lymph nodes as well as isolated hepatic and pulmonary metastases.

RESULTS AND CONCLUSION

In order to further investigate the feasibility and efficacy of such an approach, a prospective multicenter trial, in which survival and quality of life after metastatic resection and systemic chemotherapy is evaluated, has to be initiated. Additionally, local and locoregional ablation techniques or stereotactic body radiation therapy as therapeutic options for isolated metastases in PDAC need further research in order to determine their significance and benefit.