Adjuvant 5-FU-based chemoradiotherapy for patients undergoing R-1/R-2 resections for pancreatic cancer

Neoadjuvant and Adjuvant Treatments for Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma: The Current Status of Pancreatic Ductal Adenocarcinoma Treatment in Japan

Resection is the only curative treatment for pancreatic ductal adenocarcinoma (PDAC). Although the outcome of technically resectable PDAC has improved with advances in surgery and adjuvant therapy, the 5-year survival rate remains low at 20% to 40%. More effective therapy is needed. Almost 15 years ago, the National Comprehensive Cancer Network guidelines proposed a resectability classification of PDAC based on preoperative imaging. Since then, treatment strategies for PDAC have been devised based on resectability. The standard of care for resectable PDAC is adjuvant chemotherapy after R0 resection, as shown by the results of pivotal clinical trials. With regard to neoadjuvant treatment, several recent clinical trials comparing neoadjuvant treatment with upfront resection have been conducted on resectable PDAC and borderline resectable PDAC, and the benefits and efficacy of neoadjuvant treatment for pancreatic cancer has become clearer. The significance of neoadjuvant treatment for resectable PDAC remains controversial, but in borderline resectable PDAC the efficacy of neoadjuvant treatment has been further recognised, although the standard of care has not yet been established. Several promising clinical trials for PDAC are ongoing. This review presents previous and ongoing trials of perioperative treatment for resectable and borderline resectable PDAC, focusing on the difference between Asian and Western countries.

A Review of Herbal Resources Inducing Anti-Liver Metastasis Effects in Gastrointestinal Tumors via Modulation of Tumor Microenvironments in Animal Models

Liver metastases remain a major obstacle for the management of all types of tumors arising from digestive organs, and the tumor microenvironment has been regarded as an important factor in metastasis. To discover herbal candidates inhibiting the liver metastasis of tumors originating from the digestive system via the modulation of the tumor microenvironment and liver environment, we searched three representative public databases and conducted a systematic review. A total of 21 studies that employed experimental models for pancreatic (9), colon (8), and stomach cancers (4) were selected. The herbal agents included single-herb extracts (5), single compounds (12), and multiherbal decoctions (4). Curcuma longa Linn was most frequently studied for its anti-colon-liver metastatic effects, and its possible mechanisms involved the modulation of tumor microenvironment components such as vascular endothelial cells and immunity in both tumor tissues and circulating cells. The list of herbal agents and their mechanisms produced in this study is helpful for the development of anti-liver metastasis drugs in the future.

Neoadjuvant therapy for pancreatic cancer

Patients with localized pancreatic ductal adenocarcinoma (PDAC) are best treated with surgical resection of the primary tumour and systemic chemotherapy, which provides considerably longer overall survival (OS) durations than either modality alone. Regardless, most patients will have disease relapse owing to micrometastatic disease. Although currently a matter of some debate, considerable research interest has been focused on the role of neoadjuvant therapy for all forms of resectable PDAC. Whilst adjuvant combination chemotherapy remains the standard of care for patients with resectable PDAC, neoadjuvant chemotherapy seems to improve OS without necessarily increasing the resection rate in those with borderline-resectable disease. Furthermore, around 20% of patients with unresectable non-metastatic PDAC might undergo resection following 4-6 months of induction combination chemotherapy with or without radiotherapy, even in the absence of a clear radiological response, leading to improved OS outcomes in this group. Distinct molecular and biological responses to different types of therapies need to be better understood in order to enable the optimal sequencing of specific treatment modalities to further improve OS. In this Review, we describe current treatment strategies for the various clinical stages of PDAC and discuss developments that are likely to determine the optimal sequence of multimodality therapies by integrating the fundamental clinical and molecular features of the cancer.

Chronic inflammatory changes and oxidative stress in the background of "pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm"

Cases of "pancreatic ductal adenocarcinoma (PDAC) concomitant with intraductal papillary mucinous neoplasm" (IPMN) have multiple PDAC lesions more frequently than cases of "PDAC without IPMN". However, the mechanism of carcinogenesis in this former disease category remains unknown. The main objective of this work was thus to investigate the effects of chronic inflammation on carcinogenesis in PDAC cases. We selected 31 "PDAC concomitant with IPMN" patients and 58 "PDAC without IPMN" patients and pathologically evaluated their background pancreatic parenchyma. Fibrosis and inflammation scores of background pancreas were higher in "PDAC concomitant with IPMN" than in "PDAC without IPMN" (P < 0.0001 and P < 0.0001, respectively), whereas the fatty infiltration score of background pancreas was high in "PDAC without IPMN" (P = 0.0024). Immunohistochemically, the expression of 8-hydroxy-2'-deoxyguanosine (8-OHDG), an oxidative stress marker, in the background pancreas was high in "PDAC concomitant with IPMN" compared with that in "PDAC without IPMN" (P < 0.0001). Chronic inflammation activates oxidative stress in tissue throughout the pancreas and probably confers susceptibility to tumorigenesis in "PDAC concomitant with IPMN".

Concomitant Intraductal Papillary Mucinous Neoplasm in Pancreatic Ductal Adenocarcinoma Is an Independent Predictive Factor for the Occurrence of New Cancer in the Remnant Pancreas

OBJECTIVE

To determine the factors predicting the subsequent development of pancreatic ductal adenocarcinoma in remnant pancreas (PDAC-RP) after partial pancreatectomy for PDAC.

SUMMARY BACKGROUND DATA

PDAC-RP after partial pancreatectomy for PDAC is currently not so rare because of improved prognosis of PDAC patients due to recent advances in surgical techniques and adjuvant therapy. However, the predictive factors related to PDAC-RP remain unknown.

METHODS

We retrospectively reviewed the clinicopathological data of a consecutive series of 379 patients with PDAC treated by partial pancreatectomy between 1992 and 2015; 14 patients (3.69%) had PDAC-RP. Clinicopathological variables were compared between PDAC-RP and non-PDAC-RP.

RESULTS

In univariate analysis, concomitant intraductal papillary mucinous neoplasm (IPMN) (P = 0.0005), cancer location (body/tail) (P = 0.0060), and lower T factor in UICC (P = 0.0039) were correlated with PDAC-RP development. Multivariate analysis revealed concomitant IPMN (P = 0.0135) to be an independent predictive factor for PDAC-RP. PDAC concomitant with IPMN had higher cumulative incidence of PDAC-RP (47.5%/10 yrs) than PDAC without IPMN (9.96%/10 yrs) (P = 0.0071). Moreover, the density of pancreatic intraepithelial neoplasia lesions in the background pancreas of cases of PDAC concomitant with IPMN (1.86/cm) was higher than that of cases of PDAC without IPMN (0.91/cm) (P = 0.0007).

CONCLUSIONS

Concomitant IPMN in PDAC is an independent predictive factor for the development of new PDAC in remnant pancreas. Cancer susceptibility of remnant pancreas after resection for PDAC concomitant with IPMN is probably due to an increased density of pancreatic intraepithelial neoplasia lesions.

Pancreatic cancer arising from the remnant pancreas after pancreatectomy: a multicenter retrospective study by the Kyushu Study Group of Clinical Cancer

BACKGROUND

After initial pancreatic resection, local recurrence of pancreatic cancer (PC) or new primary PC can develop in the remnant. There are limited data available regarding this so-called remnant PC. The aim of this retrospective study was to clarify the clinical features and establish a treatment strategy for remnant PC.

METHODS

A multicenter retrospective study with the Kyushu Study Group of Clinical Cancer was carried out. Clinical data from 50 patients who developed remnant PC were analyzed. RAS mutation analysis of the initial tumor and of remnant PC was performed in 17 cases.

RESULTS

The initial pancreatic resections were performed for 37 invasive ductal carcinomas, and for 13 other tumors. Thirty-seven patients underwent a second pancreatectomy for remnant PC (resected group), while thirteen patients were not operated (unresected group). The median overall survival times were 42.2 months in the resected group and 12.3 months in the unresected group (HR 0.374; 95% CI 0.17-0.83). In RAS mutation analysis, 14 cases had at least 1 missense variant of KRAS, HRAS, or NRAS in the initial pancreatic tumor and/or remnant PC. The same missense variants between the initial tumor and remnant PC were discovered only in KRAS of one patient, and in HRAS of one patient. No case had completely consistent missense variants between the initial tumor and remnant PC.

CONCLUSIONS

This study found that repeated pancreatectomy for remnant PC can prolong patient survival, and RAS mutation analysis indicated that many remnant PCs are developed from metachronous multifocal origins.

Dual-Modality Immuno-PET and Near-Infrared Fluorescence Imaging of Pancreatic Cancer Using an Anti-Prostate Stem Cell Antigen Cys-Diabody

Pancreatic cancer has a high mortality rate due to late diagnosis and the tendency to invade surrounding tissues and metastasize at an early stage. A molecular imaging agent that enables both presurgery antigen-specific PET (immuno-PET) and intraoperative near-infrared fluorescence (NIRF) guidance might benefit diagnosis of pancreatic cancer, staging, and surgical resection, which remains the only curative treatment. Methods: We developed a dual-labeled probe based on A2 cys-diabody (A2cDb) targeting the cell-surface prostate stem cell antigen (PSCA), which is expressed in most pancreatic cancers. Maleimide-IRDye800CW was site-specifically conjugated to the C-terminal cys-tag (A2cDb-800) without impairing integrity or affinity (half-maximal binding, 4.3 nM). Direct radioiodination with ¹²⁴I (¹²⁴I-A2cDb-800) yielded a specific activity of 159 ± 48 MBq/mg with a radiochemical purity exceeding 99% and 65% ± 4.5% immunoreactivity (n = 3). In vivo specificity for PSCA-expressing tumor cells and biodistribution of the dual-modality tracer were evaluated in a prostate cancer xenograft model and compared with single-labeled ¹²⁴I-A2cDb. Patient-derived pancreatic ductal adenocarcinoma xenografts (PDX-PDACs) were grown subcutaneously in NSG mice and screened for PSCA expression by immuno-PET. Small-animal PET/CT scans of PDX-PDAC-bearing mice were obtained using the dual-modality ¹²⁴I-A2cDb-800 followed by postmortem NIRF imaging with the skin removed. Tumors and organs were analyzed ex vivo to compare the relative fluorescent signals without obstruction by other organs. Results: Specific uptake in PSCA-positive tumors and low nonspecific background activity resulted in high-contrast immuno-PET images. Concurrent with the PET studies, fluorescent signal was observed in the PSCA-positive tumors of mice injected with the dual-tracer ¹²⁴I-A2cDb-800, with low background uptake or autofluorescence in the surrounding tissue. Ex vivo biodistribution confirmed comparable tumor uptake of both ¹²⁴I-A2cDb-800 and ¹²⁴I-A2cDb. Conclusion: Dual-modality imaging using the anti-PSCA cys-diabody resulted in high-contrast immuno-PET/NIRF images of PDX-PDACs, suggesting that this imaging agent might offer both noninvasive whole-body imaging to localize PSCA-positive pancreatic cancer and fluorescence image-guided identification of tumor margins during surgery.

Clinical Outcome of Resected Remnant Pancreatic Cancer After Resection of the Primary Pancreatic Cancer

Purpose: Pancreatic cancer (PC) has high morbidity and mortality rates, with a poor prognosis and frequent recurrence. The postresection survival rate has increased but remains low, and remnant PC is becoming more common. This review evaluates the current literature pertaining to the clinical outcomes of patients with resected remnant PC. Material and Methods: We reviewed publications on remnant PC that included repeated and completion pancreatectomy. Clinicophysiological data were analyzed, and survival rates were calculated using the Kaplan-Meier method. Remnant PC was defined by negative margins at the initial operation, a cancer-free interval >1 year, and presence in the remnant pancreas. Results: Forty-nine cases of remnant PC selected from the literature were examined. Primary and remnant PCs had the same histopathological features in 29 of 45 patients (64.4%). The median disease-free interval was 44.3 months (12-143 months). The 1- and 3-year survival rates after repeat pancreatectomy were 81.5% and 50%, respectively, and the median survival time was 32 months. The age of the patient at the time of the first operation independently predicted survival in a multivariate analysis. Conclusion: In long-term survivors after curative resection for PC, resectable remnant PCs should be aggressively removed to improve prognosis.

Prognostic significance of B7-H4 expression in matched primary pancreatic cancer and liver metastases

Liver metastasis development in pancreatic cancer patients is common and confers a poor prognosis. Clinical relevance of biomarker analysis in metastatic tissue is necessary. B7-H4 has an inhibitory effect on T cell mediated response and may be involved in tumor development. Although B7-H4 expression has been detected in pancreatic cancer, its expression in liver metastases from pancreatic cancer is still unknown. In this study, overall 43 pancreatic cancer liver metastases (with matched primaries in 15/43 cases) and 57 pancreatic cancer cases without liver metastases or other distant metastases were analyzed for their expression of B7-H4 by immunohistochemistry. Survival curves and log-rank tests were used to test the association of B7-H4 expression with survival. B7-H4 was highly expressed in 28 (65.1%) of the 43 liver metastases and 9 (60.0%) of the 15 matched primary tumors. The expression of B7-H4 in liver metastases was significantly higher than in the matched primary tumors (p < 0.05). Patients with high B7-H4 expression in their primary pancreatic cancer had higher risk of developing liver metastases (p < 0.05). In univariate analysis, B7-H4 expression was significantly associated with the risk of death (p < 0.05). And the multivariate analysis identified that B7-H4 was an independent prognostic indicator (p < 0.05). Our results revealed B7-H4 to be associated with poor prognosis in patients with pancreatic cancer liver metastasis. B7-H4 may promote pancreatic cancer metastasis and was promising to be a potential prognostic indicator of pancreatic cancer.

Pancreatic Cancer Arising From the Remnant Pancreas: Is It a Local Recurrence or New Primary Lesion?

Local recurrence of pancreatic cancer (PC) can occur in the pancreatic remnant. In addition, new primary PC can develop in the remnant. There are limited data available regarding this so-called remnant PC. The aim of this review was to describe the characteristics and therapeutic strategy regarding remnant PC. A literature search was performed using Medline published in English according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The incidence of remnant PC has been reported to be 3% to 5%. It is difficult to distinguish local recurrence from new primary PC. Genetic diagnosis such as Kirsten rat sarcoma viral oncogene homolog mutation may resolve this problem. For patients with remnant PC, repeated pancreatectomy can be performed. Residual total pancreatectomy is the most common procedure. Recent studies have described the safety of the operation because of recent surgical progress and perioperative care. The patients with remnant PC without distant metastasis have shown good long-term outcomes, especially those who underwent repeated pancreatectomy. Adjuvant chemotherapy may contribute to longer survival. In conclusion, this review found that both local recurrence and new primary PC can develop in the pancreatic remnant. Repeated pancreatectomy for the remnant PC is a feasible procedure and can prolong patient survival.

Original Scientific Reports: Clinicopathological Findings of Remnant Pancreatic Cancers in Survivors Following Curative Resections of Pancreatic Cancers

Background

This retrospective study aimed to evaluate clinicopathological findings of remnant pancreatic cancers in survivors of invasive ductal adenocarcinomas of the pancreas (PDAC).

Methods

A group of 23 patients out of 826 who had curative resections for PDAC between 1980 and 2011 was identified and treated for metachronous pancreatic cancer.

Results

The following tubular adenocarcinomas were found at the first surgery: 3 well differentiated, 17 moderately differentiated, 1 papillary, and 1 poorly differentiated. Treatments for the remnant pancreas consisted of remnant pancreatectomy in 12 patients, chemotherapy in 6, and the best supportive care in 5. The mean time to treatment was 74.2 months. The 12 patients who received remnant resections had 10 PDACs and 2 intraductal papillary mucinous carcinomas. The median survival time was 31.6 months, and 8 patients are still alive.

Conclusions

Long-term survivors after curative resection for pancreatic cancer should receive follow-up for remnant pancreatic cancer, and aggressive resection should be considered for more favorable prognosis of PDAC.

Neoadjuvant modified (m) FOLFIRINOX for locally advanced unresectable (LAPC) and borderline resectable (BRPC) adenocarcinoma of the pancreas

BACKGROUND

For patients with metastatic pancreatic cancer, FOLFIRINOX (fluorouracil [5-FU], leucovorin [LV], irinotecan [IRI], and oxaliplatin) has shown improved survival rates compared with gemcitabine but with significant toxicity, particularly in patients with a high tumor burden. Because of reported response rates exceeding 30 %, the authors began to use a modified (m) FOLFIRINOX regimen for patients with advanced nonmetastatic disease aimed at downstaging for resection. This report describes their experience with mFOLFIRINOX and aggressive surgical resection.

METHODS

Between January 2011 and August of 2013, 43 patients with borderline resectable pancreatic cancer (BRPC, n = 18) or locally advanced pancreatic cancer (LAPC, n = 25) were treated with mFOLFIRINOX (no bolus 5-FU, no LV, and decreased IRI). Radiation was used based on response and intended surgery. Charts were retrospectively reviewed to assess response, toxicities, and extent of resection when possible.

RESULTS

The most common grade 3/4 toxicity was diarrhea in six patients (14 %) with no grade 3/4 neutropenia or thrombocytopenia. Resection was attempted in 31 cases (72 %) and accomplished in 22 cases (51.1 %) including 11 of 25 LAPC cases (44 %). Vascular resection was required in 4 cases (18 %), with R0 resection in 86.4 % of the resections. Complications occurred in 6 cases (27 %), with no perioperative deaths. The median progression-free survival period was 18 months if the resection was achieved compared with 8 months if no resection was performed (p < 0.001).

CONCLUSION

Neoadjuvant mFOLFIRINOX is an effective, well-tolerated regimen for patients with advanced nonmetastatic pancreatic cancer. When mFOLFIRINOX is coupled with aggressive surgery, high resection rates are possible even when the initial imaging shows locally advanced disease. Although data are still maturing, resection appears to offer at least a progression-free survival advantage.

Huachansu injection inhibits metastasis of pancreatic cancer in mice model of human tumor xenograft

Background

Huachansu injection (HCS) is a water-soluble preparation made from Bufo gargarizans’s skin, which has been widely used in clinics for tumor therapy in China. Though the anti-cancer activity of HCS has been verified through studies in vitro and in vivo, there is little research about its potential anti-metastasis effect. The primary objective of this study was to assess the effects of HCS on both the invasion of pancreatic cancer cells in vitro and on the progression of liver metastasis in vivo in this study.

Methods

HCS anti-metastasis potential was accessed using both assay of Cell viability and invasion in vitro, and then further Establishing xenograft model in nude mice. In the cell-based assay, mRNA and protein expression of MMP-2, MMP-9 and VEGF was detected by semi-quantitative RT-PCR and western blotting. In animal experiment, liver metastasis nodules and change of liver-body ratio was observed. Meanwhile, correlation of the CA19-9 and CEA content in serum with the progression of liver metastasis was analyzed.

Result

We observed that HCS prevented the invasion of cancer cells, with inhibiting the expressions of MMP-2 and MMP-9, and reduced not only the number of metastasis nodules but the ratio of liver-body weight as well. Furthermore, HCS decreased the expression of MMP-2, MMP-9 and VEGF in liver metastasis, while also reducing CA19-9 contents in serum. In addition, correlation analysis indicated that the level of CA19-9 in serum was closely related to the number of liver metastasis nodules.

Conclusion

Our experimental results suggest that HCS has some anti-metastasis potential to suppress the growth of liver metastasis by decreasing the expression of MMP-2 and MMP-9 as well as VEGF.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6882-14-483) contains supplementary material, which is available to authorized users.

Effect of chemoradiotherapy and neoadjuvant chemoradiotherapy in resectable pancreatic cancer: a systematic review and meta-analysis

OBJECTIVE

Controversy remains existed whether chemoradiotherapy (CRT), especially neoadjuvant chemoradiotherapy (neoadjuvant CRT) achieves a significant benefit in resectable pancreatic cancer (PC) treatment. In this meta-analysis, we aimed to clarify the benefits of CRT and neoadjuvant CRT in resectable PC.

METHODS

Eligible trials were identified from MEDLINE, EMBASE, Cochrane center, China National Knowledge Internet and Wanfang database since their inception to July 31, 2013. Only patients with resectable PC, who underwent tumor resection and received CRT and/or neoadjuvant CRT, were enrolled. The treatment outcomes were overall survival (OS) and progression-free survival (PFS). Hazard ratio (HR) with a 95% confidence interval (CI) was used to measure the pooled effect according to a fixed-effects model. The statistical heterogeneity between trials was detected by χ(2) and I (2) test. Sensitivity analyses were also carried out.

RESULTS

A total of 28 studies were identified as relevant, but only 17 studies with a total of 3,088 patients were included in the comparison between CRT versus non-CRT, and a total number of three studies with 189 patients included in the comparison between neoadjuvant CRT versus postoperative CRT. The comparison between CRT and non-CRT showed that the overall pooled HR for death was 0.96 (95% CI 0.89-1.03; P = 0.28). The HR for progress was 0.83 (95% CI 0.68-1.03, P = 0.09). Comparison between neoadjuvant CRT and adjuvant CRT revealed a pooled HR of 0.93 (95% CI 0.69-1.25; P = 0.62).

CONCLUSIONS

This meta-analysis showed that CRT showed no significant effect on OS and PFS when compared to non-CRT. Neoadjuvant CRT showed no significant effect over postoperative adjuvant CRT.

Pancreatic cancer in the remnant pancreas following primary pancreatic resection

PURPOSE

To clarify the clinical features of cancer in the pancreatic remnant.

METHODS

We retrospectively reviewed the clinical and pathological findings of 10 patients who developed remnant pancreatic cancer in our hospital between 2002 and 2012. The KRAS sequences in both the initial pancreatic tumor and remnant pancreatic cancer were examined in two patients.

RESULTS

Eight patients underwent a second pancreatectomy for remnant pancreatic cancer (resected group), while two patients were not operated on and underwent chemotherapy (unresected group). The remnant pancreatic cancer developed at the cut end of the pancreas (pancreaticogastrostomy site) in four patients. In the resected group, four patients died 17 months after the emergence of the remnant pancreatic cancer and four patients survived during the median 40.5-month observation period. The median survival of the unresected group after the emergence of the remnant pancreatic cancer was 10 months. The findings of the KRAS sequencing and immunohistological staining of the remnant pancreatic cancer for MUC1 and MUC2 in the two patients were consistent with those of the initial pancreatic tumor in one patient, and not consistent in the other.

CONCLUSIONS

Our results suggest that both local recurrence and a new primary cancer can develop in the pancreatic remnant, and repeated pancreatectomy can prolong survival.

Qingyihuaji formula inhibits progress of liver metastases from advanced pancreatic cancer xenograft by targeting to decrease expression of Cyr61 and VEGF

OBJECTIVE

To observe the effects of Qingyihuaji formula (QYHJ) on the progression of liver metastases from human pancreatic cancer and to detect the expression changes of some biological factors associated with angiogenesis and metastasis during the development of advanced pancreatic cancer.

METHODS

Nude mice were inoculated intrasplenically with human pancreatic cancer cell line SW1990 and then randomly assigned into 4 groups: a control group and groups QYHJ-A, QYHJ-B, and QYHJ-C. Following this, the mice were treated with or without QYHJ formula for 4 weeks and were sacrificed at the end of the sixth week. The changes in body weight were observed, followed by the livers being excised and weighed. Then, both the numbers and the volume of metastatic nodules per liver were evaluated. Subsequently, the expressions of MMPs, VEGF, and Cyr61 in the tissue of liver metastases were detected by reverse transcription polymerase chain reaction, immunohistochemistry, or Western blot. Finally, the correlation was evaluated between the expressions of the factors associated with metastasis and the growth of liver metastasis.

RESULTS

Liver metastases were identified in 11 of 15 mice (73%) in the control group, 9 of 15 mice (60%) in group QYHJ-A, 6 of 14 mice (43%) in group QYHJ-B, and 8 of 14 mice (57%) in group QYHJ-C both the number and the volume of metastatic nodules per liver same as the ratio of liver-body weight in QYHJ groups were significantly less than the controlled group (P < 0.05). The expressions of Cyr61, MMP-2, and VEGF at the levels of mRNA and protein were decreased in the QYHJ groups when compared with the control, as confirmed by immunohistochemistry detection (P < .05). However, no significant difference was observed in the mRNA expression of MMP-1 and MMP-9 between the QYHJ groups and the control group (P > .05). Regression analysis indicated that QYHJ possessed an evident inhibition against the progression of liver metastasis by downregulating the expression of VEGF and Cyr61 rather than MMP-2.

CONCLUSIONS

The QYHJ formula exerted an inhibitory effect on the growth of liver metastasis from pancreatic cancer, perhaps by targeting VEGF and Cyr61 to some extent.

Multimodality treatment of pancreatic cancer with liver metastases using chemotherapy, radiation therapy, and/or Chinese herbal medicine

OBJECTIVE

To explore the utility of multidisciplinary approaches in the treatment of patients with pancreatic cancer with liver metastases (PCLM).

METHODS

From 2002 to 2007, a total of 164 consecutive patients with PCLM treated with chemotherapy, radiation therapy, and/or Chinese herbal medicine were included in this study. Clinical parameters, treatments received, and survival time from initial diagnosis were analyzed.

RESULTS

Of the 164 patients, 113 (69%) were men and 51 (31%) were women, with median age of 58 years. One hundred thirty-two patients (80%) had synchronous liver metastases, and 57 patients (35%) had extrahepatic metastases. Overall median survival time of the 164 patients was 4.7 months; 23 (14%) were alive at least 12 months after initial diagnosis of liver metastases. Karnofsky performance status of less than 80, weight loss (>10% within 6 months), ascites, and carbohydrate antigen 19-9 of 1000 U/mL or greater were the most relevant predictors of poor survival. Multivariate analysis showed that chemotherapy and Chinese herbal medicine were protective factors.

CONCLUSIONS

Multimodality treatment is well tolerated by patients with PCLM and may be effective in prolonging their survival. Awareness of the implications of these prognostic factors may assist in evaluating the survival potential of patients and selecting the most appropriate treatments.

EUS-guided FNA of local recurrence of pancreatic cancer after surgical resection

BACKGROUND

EUS-guided FNA (EUS-FNA) is a sensitive test for the preoperative diagnosis of pancreatic cancer. Its use for diagnosing local tumor recurrence after surgical resection has not been described.

OBJECTIVE

To determine the sensitivity of EUS-FNA for this indication.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral hospital in the United States.

PATIENTS

Consecutive patients referred for EUS with clinical and/or radiographic suspicion of pancreatic cancer recurrence.

INTERVENTIONS

EUS ± FNA of retroperitoneal mass.

MAIN OUTCOME MEASUREMENT

Sensitivity of EUS-FNA.

RESULTS

Seventeen patients (9 male, median age 71 years) underwent EUS at a median of 17 months (range 7-46 months) after a classic Whipple procedure (n = 7), pylorus-sparing Whipple procedure (n = 7), or distal pancreatectomy (n = 3) for suspected local recurrence of pancreatic cancer. The primary tumor (median size 2.5 cm, range 1.5-7.9 cm) was located in the head in 14 patients, the body in 1, and the tail in 2. Final surgical margins at any site were positive in only 1 of 17 patients (+ retroperitoneal margin). At the time of suspected recurrence, 4 patients (24%) were asymptomatic. EUS disclosed a mass (median size 21 mm, range 12-30 mm) in 16 of 17 patients (94%). Transgastric EUS-FNA (n = 16, median 4.5 passes, range 2-10) disclosed recurrent malignancy in 13 of 16 (79%), atypical cells in 1 of 16 (7%), and benign cytology in 2 of 16 (14%). Subsequent radiographic evidence of increasing tumor burden was seen in 1 of 2 patients with benign cytology; however, follow-up for the 2 other patients with benign biopsy specimens was not available. Depending on the status of the 2 patients without available follow-up, the sensitivity, specificity, and accuracy of EUS-FNA for the diagnosis of recurrent cancer ranged from 81% to 93%, was 100%, and ranged from 81% to 93%, respectively.

LIMITATIONS

Small, single-center retrospective cohort.

CONCLUSIONS

EUS-FNA is sensitive for the diagnosis of retroperitoneal recurrence of pancreatic cancer after surgical resection.

Utilization and determinants of adjuvant therapy among older patients who receive curative surgery for pancreatic cancer

OBJECTIVE

We conducted a population-based study to describe the utilization, determinants, and survival effects of adjuvant therapies after surgery among older patients with pancreatic cancer.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients older than 65 years who received surgical resection for pancreatic cancer during 1992-2002. We constructed multiple logistic regression models to examine patient, clinical, and hospital factors associated with receiving adjuvant therapy. Cox proportional hazards models were used to examine the effect of therapy on survival.

RESULTS

Approximately 49% of patients received adjuvant therapy after surgery. Patient factors associated with increased receipt of adjuvant therapy included more recent diagnosis, younger age, stage II disease, higher income, and geographic location. Hospital factors associated with increased receipt of adjuvant therapy included cooperative group membership and larger size. Adjuvant treatments associated with a significant reduction in 2-year mortality (relative to surgery alone) were chemoradiation or radiation alone but not chemotherapy alone.

CONCLUSIONS

Our findings suggest that adjuvant chemoradiation and, to a lesser degree, radiation only are associated with a reduction in the risk of mortality among older patients who undergo surgery for pancreatic cancer. However, receipt of adjuvant therapy varied by period and geography as well as by certain patient and hospital factors.

Surgery for recurrent pancreatic ductal adenocarcinoma

OBJECTIVE

This study evaluates the outcome of patients who underwent surgery for recurrent pancreatic cancer.

SUMMARY BACKGROUND DATA

Recurrence of pancreatic ductal adenocarcinoma occurs in up to 80% of pancreatic cancer patients within 2 years of a potential curative resection because, in most cases, occult (local and/or distant) micrometastases are present at the time of the initial resection.

METHODS

Thirty patients were operated for recurrent pancreatic cancer between October 2001 and April 2005. Median time between the initial resection and recurrence was 12.0 months. While 15 patients were resected, 15 patients either underwent palliative bypass or only exploration. Prospectively recorded data were analyzed retrospectively. Survival analysis was performed using Kaplan-Meier estimation and log-rank test.

RESULTS

The overall median survival of patients with recurrent disease was 29.0 months. After the first reresection/exploration for recurrent disease, the median survival was 11.4 months. There was a tendency of increased median survival in the group of patients undergoing resection (17.0 months) compared with the bypass/exploration group (9.4 months), although this difference was not significant (P = 0.084). In addition, patients with a prolonged interval (>9 months) from resection to recurrence were more likely to benefit from reresection compared with patients with recurrence within 9 months (median survival 17.0 vs. 7.4 months; P = 0.004). The in-hospital morbidity and mortality rate of resected patients was 20% and 6.7% compared with 13.3% and 0% of patients who underwent only exploration/palliative bypass.

CONCLUSION

Resection for recurrent pancreatic cancer can be carried out safely. Further studies are required to address the question whether a subgroup of patients might actually benefit from this procedure.

Impact of gemcitabine on the survival of patients with stage IV pancreatic cancer

OBJECTIVES

The prognosis of patients with advanced pancreatic cancer remains very poor. This study was designed to elucidate the prognostic factors of patients with pancreatic cancer to evaluate appropriate treatment with gemcitabine.

METHODS

Ninety-nine consecutive patients with stage IV pancreatic cancer were treated in the gemcitabine era at the Kobe University Hospital. Prognostic variables for survival were analyzed (sex, age, performance status, main site of the tumor, tumor size, major vessel invasion, distal metastasis, resection, gemcitabine, radiation, and pathological factors). The Cox proportional hazards model was used to determine the factors influencing the survival of patients with stage IV pancreatic cancer.

RESULTS

Multivariate analysis revealed that pancreatic resection, gemcitabine, and distant metastasis significantly influenced the survival of all patients with stage IV pancreatic cancer. Pancreatic resection and gemcitabine were significant factors influencing the survival of patients with stage IVa pancreatic cancer, whereas gemcitabine was the strongest factor influencing stage IVb pancreatic cancer.

CONCLUSIONS

Gemcitabine has a possible role for stage IV pancreatic cancer.