1
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Huang K, Yuan X, Zhao P, He Y. Effect of chemotherapy on prognosis in patients with primary pancreatic signet ring cell carcinoma: A large real-world study based on machine learning. PLoS One 2024; 19:e0302685. [PMID: 38739633 PMCID: PMC11090313 DOI: 10.1371/journal.pone.0302685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/09/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Primary pancreatic signet ring cell carcinoma (PSRCC), an extremely rare histologic variant of pancreatic cancer, has a poor prognosis. This study aimed to investigate the prognostic value of chemotherapy in PSRCC. METHODS Patients with PSRCC between 2000 and 2019 were identified using the Surveillance Epidemiology and End Results (SEER) database. The main outcomes in this study were cancer-specific survival (CSS) and overall survival (OS). The baseline characteristics of patients were compared using Pearson's Chi-square test. Kaplan-Meier analysis was used to generate the survival curves. Least absolute shrinkage and selection operator (LASSO), univariate and multivariate Cox regression models, and Random Survival Forest model were used to analyze the prognostic variables for OS and CSS. The variance inflation factors (VIFs) were used to analyze whether there was an overfitting problem. RESULTS A total of 588 patients were identified. Chemotherapy was an independent prognostic factor for OS and CSS, and significantly associated with OS (HR = 0.33, 95% CI = 0.27-0.40, P <0.001) and CSS (HR = 0.32, 95% CI = 0.26-0.39, P <0.001). CONCLUSIONS Chemotherapy showed beneficial effects on OS and CSS in patients with PSRCC and should be recommended in clinical practice.
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Affiliation(s)
- Kun Huang
- Departments of General Surgery, Mian Yang Hospital of Traditional Chinese Medicine, Mianyang, Sichuan, P.R. China
| | - Xinzhu Yuan
- Department of Nephrology, The Second Clinical Medical Institution of North Sichuan Medical College (Nanchong Central Hospital) and Nanchong Key Laboratory of Basic Science & Clinical Research on Chronic Kidney Disease, Nanchong, Sichuan, P.R. China
| | - Pingwu Zhao
- Departments of General Surgery, Mian Yang Hospital of Traditional Chinese Medicine, Mianyang, Sichuan, P.R. China
| | - Yunshen He
- Departments of General Surgery, Mian Yang Hospital of Traditional Chinese Medicine, Mianyang, Sichuan, P.R. China
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2
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Endo Y, Kitago M, Kitagawa Y. Evidence and Future Perspectives for Neoadjuvant Therapy for Resectable and Borderline Resectable Pancreatic Cancer: A Scoping Review. Cancers (Basel) 2024; 16:1632. [PMID: 38730584 PMCID: PMC11083108 DOI: 10.3390/cancers16091632] [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: 02/24/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Pancreatic cancer (PC) is a lethal disease that requires innovative therapeutic approaches to enhance the survival outcomes. Neoadjuvant treatment (NAT) has gained attention for resectable and borderline resectable PC, offering improved resection rates and enabling early intervention and patient selection. Several retrospective studies have validated its efficacy. However, previous studies have lacked intention-to-treat analyses and appropriate resectability classifications. Randomized comparative trials may help to enhance the clinical applicability of evidence. Therefore, after searching the MEDLINE database, this scoping review presents a comprehensive summary of the evidence from published (n = 14) and ongoing (n = 12) randomized Phase II and III trials. Diverse regimens and their outcomes were explored for both resectable and borderline resectable PC. While some trials have supported the efficacy of NAT, others have demonstrated no clear survival benefits for patients with resectable PC. The utility of NAT has been confirmed in patients with borderline resectable PC, but the optimal regimens remain debatable. Ongoing trials are investigating novel regimens, including immunotherapy, thereby highlighting the dynamic landscape of PC treatment. Studies should focus on biomarker identification, which may enable precision in oncology. Future endeavors aim to refine treatment strategies, guided by precision oncology.
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Affiliation(s)
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo 160-8582, Japan; (Y.E.); (Y.K.)
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Huan L, Yu F, Cao D, Zhou H, Qin M, Cao Y. Comparison of neoadjuvant treatment and surgery first for resectable or borderline resectable pancreatic carcinoma: A systematic review and network meta-analysis of randomized controlled trials. PLoS One 2024; 19:e0295983. [PMID: 38451955 PMCID: PMC10919605 DOI: 10.1371/journal.pone.0295983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/03/2023] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Current treatment recommendations for resectable or borderline pancreatic carcinoma support upfront surgery and adjuvant therapy. However, neoadjuvant therapy (NT) seems to increase prognosis of pancreatic carcinoma and come to everyone's attention gradually. Randomized controlled trials offering comparison with the NT are lacking and optimal neoadjuvant treatment regimen still remains uncertain. This study aims to compare both treatment strategies for resectable or borderline resectable pancreatic cancer. METHODS The PRISMA checklist was used as a guide to systematically review relevant peer-reviewed literature reporting primary data analysis. We searched PubMed, Medline, EMBASE, Cochrane Datebase and related reviews for randomized controlled trials comparing neoadjuvant therapy with surgery first for resectable or borderline resectable pancreatic carcinoma. We estimated relative hazard ratios (HRs) for median overall survival and ratios risks (RRs) for microscopically complete (R0) resection among different neoadjuvant regimens and major complications. We assessed the effects of neoadjuvant therapy on R0 resection rate and median overall survival with Bayesian analysis. RESULTS Thirteen eligible articles were included. Eight studies performed comparison neoadjuvant therapy with surgery first, and R0 resection rate was recorded in seven studies. Compared with surgery first, neoadjuvant therapy did increase the R0 resection rate (RR = 1.53, I2 = 0%, P< 0.00001), there was a certain possibility that gemcitabine + cisplatin (Gem+Cis) + Radiotherapy was the most favorable in terms of the fact that there was no significant difference concerning the results from the individual studies. In direct comparison, four studies were included and estimated that Neoadjuvant therapy improved mOS compared with upfront surgery (HR 0.68, 95% CI 0.58-0.92; P = 0.012; I2 = 15%), after Bayesian analysis it seemed that regimen with Cisplatin/ Epirubicin then Gemcitabine/ Capecitabine (PEXG) was most likely the best with a relatively small sample size. The rate of major surgical complications was available for six studies and ranged from 11% to 56% with neoadjuvant therapy and 11% to 45% with surgery first. There was no significant difference between neoadjuvant therapy and surgery first, also with a high heterogeneity (RR = 0.96, 95%CI = 0.65-1.43; P = 0.85; I2 = 46%). CONCLUSION In conclusion neoadjuvant therapy might offer benefit over up-front surgery. Neoadjuvant therapy increased the R0 resection rate with gemcitabine + cisplatin + Radiotherapy that was the most favorable and improved mOS with Cisplatin/ Epirubicin then Gemcitabine/ Capecitabine (PEXG) that was most likely the best.
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Affiliation(s)
- Lu Huan
- Department of Hepatopancreatobiliary Surgery, Chongqing Fifth People’s Hospital, Chongqing, Chongqing, China
| | - Fucai Yu
- Department of Hepatopancreatobiliary Surgery, Chongqing Fifth People’s Hospital, Chongqing, Chongqing, China
| | - Ding Cao
- Department of Hepatopancreatobiliary Surgery, Chongqing Fifth People’s Hospital, Chongqing, Chongqing, China
| | - Hantao Zhou
- Department of Hepatopancreatobiliary Surgery, Chongqing Fifth People’s Hospital, Chongqing, Chongqing, China
| | - Maoling Qin
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, Chongqing, China
| | - Yang Cao
- Department of Hepatopancreatobiliary Surgery, Chongqing Fifth People’s Hospital, Chongqing, Chongqing, China
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Rehman OU, Fatima E, Nadeem ZA, Azeem A, Motwani J, Imran H, Mehboob H, Khan A, Usman O. Efficacy of Cisplatin-Containing Chemotherapy Regimens in Patients of Pancreatic Ductal Adenocarcinoma: A Systematic Review and Meta-analysis. J Gastrointest Cancer 2024:10.1007/s12029-024-01025-7. [PMID: 38315331 DOI: 10.1007/s12029-024-01025-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND The relative success of cisplatin-based chemotherapy regimens for PDAC in clinical trials warrants a review of the literature to assess the cumulative results. This study aims to assess the efficacy of cisplatin-containing regimens for PDAC in terms of survival and response outcomes using a systematic review and proportional meta-analysis. METHODS In this study, an electronic search was conducted on PubMed, Cochrane Library, Scopus, and Google Scholar to find relevant literature. The random effects model was used to assess pooled overall response rate, stable disease rate, progressive disease rate, 1-year overall survival rate, and their 95% CIs. Publication bias was assessed using funnel plot symmetry and the one-tailed Eggers' test. In all cases, p-value < 0.05 was indicative of significant results. The review is registered with PROSPERO: CRD42023459243. RESULTS A total of 34 studies consisting of 1599 patients were included in this review. All the included studies were of good quality. In total, 906 patients were male, and the median age of the patients was 58-69 years. Overall, 599 patients had cancer of the pancreatic head, 139 had cancer of the pancreatic body, and 102 patients had cancer of the pancreatic tail. The pooled risk ratios (RRs) revealed an overall response rate of 19.2% (95% CI, 14.6-24.2%), a stable disease rate of 42.3% (95% CI, 36.6-48.8), a 1-year overall survival rate of 40% (95% CI, 34.3-45.8), and progressive disease rate of 24.7% (95% CI, 18.8-31.2). Commonly reported adverse events were anemia, thrombocytopenia, abdominal adverse events, neutropenia, fatigue, leukopenia, alopecia, anorexia, mucositis, stomatitis, and hepatobiliary adverse events. CONCLUSION Cisplatin-containing regimens have shown moderate efficacy with significant improvement in overall survival at 1 year, stable disease rate, and progressive disease rate; however, only a small percentage of patients achieved an overall response rate.
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Affiliation(s)
- Obaid Ur Rehman
- Department of Medicine, Services Institute of Medical Sciences, Lahore, 54000, Pakistan.
| | - Eeshal Fatima
- Department of Medicine, Services Institute of Medical Sciences, Lahore, 54000, Pakistan
| | - Zain Ali Nadeem
- Department of Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Arish Azeem
- University of Warmia and Mazury, Olszytn, Poland
| | - Jatin Motwani
- Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Habiba Imran
- Department of Medicine, Services Institute of Medical Sciences, Lahore, 54000, Pakistan
| | - Hadia Mehboob
- Department of Medicine, Services Institute of Medical Sciences, Lahore, 54000, Pakistan
| | - Alishba Khan
- Karachi Institute of Medical Sciences, CMH Malir, Karachi, Pakistan
| | - Omer Usman
- Texas Tech University Health Sciences Center El Paso/Transmountain, El Paso, TX, USA
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5
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de Jesus VHF, Riechelmann RP. Current Treatment of Potentially Resectable Pancreatic Ductal Adenocarcinoma: A Medical Oncologist's Perspective. Cancer Control 2023; 30:10732748231173212. [PMID: 37115533 PMCID: PMC10155028 DOI: 10.1177/10732748231173212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Pancreatic cancer has traditionally been associated with a dismal prognosis, even in early stages of the disease. In recent years, the introduction of newer generation chemotherapy regimens in the adjuvant setting has improved the survival of patients treated with upfront resection. However, there are multiple theoretical advantages to deliver early systemic therapy in patients with localized pancreatic cancer. So far, the evidence supports the use of neoadjuvant therapy for patients with borderline resectable pancreatic cancer. The benefit of this treatment sequence for patients with resectable disease remains elusive. In this review, we summarize the data on adjuvant therapy for pancreatic cancer and describe which evidence backs the use of neoadjuvant therapy. Additionally, we address important issues faced in clinical practice when treating patients with localized pancreatic cancer.
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6
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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7
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Zhang HQ, Li J, Tan CL, Chen YH, Zheng ZJ, Liu XB. Neoadjuvant therapy in resectable pancreatic cancer: A promising curative method to improve prognosis. World J Gastrointest Oncol 2022; 14:1903-1917. [PMID: 36310705 PMCID: PMC9611436 DOI: 10.4251/wjgo.v14.i10.1903] [Citation(s) in RCA: 3] [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: 06/26/2022] [Revised: 08/05/2022] [Accepted: 09/07/2022] [Indexed: 02/05/2023] Open
Abstract
Currently, 15 randomized controlled trials (RCTs) have been designed to investigate whether neoadjuvant therapy (NAT) benefits patients with resectable pancreatic adenocarcinoma (R-PA) compared to surgery alone. Five of them have acquired results so far; however, corresponding conclusions have not been obtained. We speculated that the reason for this phenomenon could be that some prognostic factors had proven to be adverse through upfront surgery curative patterns, but some of them were not regarded as independent baseline characteristics, which is important to obtaining comparability between the NAT and upfront surgery groups. This fact could cause bias and lead to the difference in the outcomes of RCTs. In this review, we collate data about risk factors (such as tumor size, resection margin, and lymph node status) influencing the prognoses of patients with R-PA from five RCTs and discuss the possible reasons for the varying outcomes.
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Affiliation(s)
- Hao-Qi Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jing Li
- Department of Operating Room/West China School of Nursing, 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
| | - Yong-Hua Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zhen-Jiang Zheng
- 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
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8
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Puleo A, Malla M, Boone BA. Defining the Optimal Duration of Neoadjuvant Therapy for Pancreatic Ductal Adenocarcinoma: Time for a Personalized Approach? Pancreas 2022; 51:1083-1091. [PMID: 37078929 PMCID: PMC10144367 DOI: 10.1097/mpa.0000000000002147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 11/03/2022] [Indexed: 04/21/2023]
Abstract
ABSTRACT Despite recent advances, pancreatic ductal adenocarcinoma (PDAC) continues to be associated with dismal outcomes, with a cure evading most patients. While historic treatment for PDAC has been surgical resection followed by 6 months of adjuvant therapy, there has been a recent shift toward neoadjuvant treatment (NAT). Several considerations support this approach, including the characteristic early systemic spread of PDAC, and the morbidity often surrounding pancreatic resection, which can delay recovery and preclude patients from starting adjuvant treatment. The addition of NAT has been suggested to improve margin-negative resection rates, decrease lymph node positivity, and potentially translate to improved survival. Conversely, complications and disease progression can occur during preoperative treatment, potentially eliminating the chance of curative resection. As NAT utilization has increased, treatment durations have been found to vary widely between institutions with an optimal duration remaining undefined. In this review, we assess the existing literature on NAT for PDAC, reviewing treatment durations reported across retrospective case series and prospective clinical trials to establish currently used approaches and seek the optimal duration. We also analyze markers of treatment response and review the potential for personalized approaches that may help clarify this important treatment question and move NAT toward a more standardized approach.
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Affiliation(s)
- Amanda Puleo
- From the Division of Surgical Oncology, Department of Surgery
| | - Midhun Malla
- Section of Hematology/Oncology, Department of Medicine
| | - Brian A. Boone
- From the Division of Surgical Oncology, Department of Surgery
- Department of Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV
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9
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O'Shea AE, Bohan PMK, Carpenter EL, McCarthy PM, Adams AM, Chick RC, Bader JO, Krell RW, Peoples GE, Clifton GT, Nelson DW, Vreeland TJ. Downstaging of Pancreatic Adenocarcinoma With Either Neoadjuvant Chemotherapy or Chemoradiotherapy Improves Survival. Ann Surg Oncol 2022; 29:6015-6028. [PMID: 35583691 DOI: 10.1245/s10434-022-11800-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 04/05/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) or chemoradiation (NAC+XRT) is incorporated into the treatment of localized pancreatic adenocarcinoma (PDAC), often with the goal of downstaging before resection. However, the effect of downstaging on overall survival, particularly the differential effects of NAC and NAC+XRT, remains undefined. This study examined the impact of downstaging from NAC and NAC+XRT on overall survival. METHODS The National Cancer Data Base (NCDB) was queried from 2006 to 2015 for patients with non-metastatic PDAC who received NAC or NAC+XRT. Rates of overall and nodal downstaging, and pathologic complete response (pCR) were assessed. Predictors of downstaging were evaluated using multivariable logistic regression. Overall survival (OS) was assessed with Kaplan-Meier and Cox proportional hazards modeling. RESULTS The study enrolled 2475 patients (975 NAC and 1500 NAC+XRT patients). Compared with NAC, NAC+XRT was associated with higher rates of overall downstaging (38.3 % vs 23.6 %; p ≤ 0.001), nodal downstaging (16.0 % vs 7.8 %; p ≤ 0.001), and pCR (1.7 % vs 0.7 %; p = 0.041). Receipt of NAC+XRT was independently predictive of overall (odds ratio [OR] 2.28; p < 0.001) and nodal (OR 3.09; p < 0.001) downstaging. Downstaging by either method was associated with improved 5-year OS (30.5 vs 25.2 months; p ≤ 0.001). Downstaging with NAC was associated with an 8-month increase in median OS (33.7 vs 25.6 months; p = 0.005), and downstaging by NAC+XRT was associated with a 5-month increase in median OS (30.0 vs 25.0 months; p = 0.008). Cox regression showed an association of overall downstaging with an 18 % reduction in the risk of death (hazard ratio [HR] 0.82; 95 % confidence interval, 0.71-0.95; p = 0.01) CONCLUSION: Downstaging after neoadjuvant therapies improves survival. The addition of radiation therapy may increase the rate of downstaging without affecting overall oncologic outcomes.
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Affiliation(s)
- Anne E O'Shea
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA.
| | | | | | - Patrick M McCarthy
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Robert C Chick
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Julia O Bader
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Robert W Krell
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | | | - Guy T Clifton
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Timothy J Vreeland
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
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10
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Pijnappel EN, Suurmeijer JA, Koerkamp BG, Kos M, Siveke JT, Salvia R, Ghaneh P, van Eijck CHJ, van Etten-Jamaludin FS, Abrams R, Brasiuniene B, Büchler MW, Casadei R, van Laethem JL, Berlin J, Boku N, Conroy T, Golcher H, Sinn M, Neoptolemos JP, van Tienhoven G, Besselink MG, Wilmink JW, van Laarhoven HWM. Consensus Statement on Mandatory Measurements for Pancreatic Cancer Trials for Patients With Resectable or Borderline Resectable Disease (COMM-PACT-RB): A Systematic Review and Delphi Consensus Statement. JAMA Oncol 2022; 8:929-937. [PMID: 35446336 DOI: 10.1001/jamaoncol.2022.0168] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Pancreatic cancer is the third most common cause of cancer death; however, randomized clinical trials (RCTs) of survival in patients with resectable pancreatic cancer lack mandatory measures for reporting baseline and prognostic factors, which hampers comparisons between outcome measures. Objective To develop a consensus on baseline and prognostic factors to be used as mandatory measurements in RCTs of resectable and borderline resectable pancreatic cancer. Evidence Review We performed a systematic literature search of the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Embase for RCTs on resectable and borderline resectable pancreatic cancer with overall survival as the primary outcome. We produced a systematic summary of all baseline and prognostic factors identified in the RCTs. A Delphi panel that included 13 experts was surveyed to reach a consensus on mandatory and recommended baseline and prognostic factors. Findings The 42 RCTs that met inclusion criteria reported a total of 60 baseline and 19 prognostic factors. After 2 Delphi rounds, agreement was reached on 50 mandatory baseline and 20 mandatory prognostic factors for future RCTs, with a distinction between studies of neoadjuvant vs adjuvant treatment. Conclusion and Relevance This findings of this systematic review and international expert consensus have produced this Consensus Statement on Mandatory Measurements in Pancreatic Cancer Trials for Resectable and Borderline Resectable Disease (COMM-PACT-RB). The baseline and prognostic factors comprising the mandatory measures will facilitate better comparison across RCTs and eventually will enable improved clinical practice among patients with resectable and borderline resectable pancreatic cancer.
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Affiliation(s)
- Esther N Pijnappel
- Department of Medical Oncology, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Milan Kos
- Department of Medical Oncology, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jens T Siveke
- Institute for Developmental Cancer Therapeutics, West German Cancer Center, University Medicine Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium and German Cancer Research Center, Heidelberg, Germany
| | | | - Paula Ghaneh
- Department of Molecular and Clinical Cancer Medicine University of Liverpool, Liverpool, UK
| | | | | | - Ross Abrams
- Sharett Institute of Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Birute Brasiuniene
- Department of Medical Oncology, National Cancer Institute, Faculty of Medicine, Vilnius University, Lithuania
| | - Markus W Büchler
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Jean-Luc van Laethem
- Department of Gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jordan Berlin
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, US
| | - Narikazu Boku
- Division of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Thierry Conroy
- Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Henriette Golcher
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Marianne Sinn
- Charite-Universitatsmedizin Berlin, CONKO study group, Berlin, Germany
- University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
| | - John P Neoptolemos
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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11
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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12
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Gugenheim J, Crovetto A, Petrucciani N. Neoadjuvant therapy for pancreatic cancer. Updates Surg 2022; 74:35-42. [PMID: 34628591 PMCID: PMC8502083 DOI: 10.1007/s13304-021-01186-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/30/2021] [Indexed: 12/12/2022]
Abstract
Multimodal treatment including surgery and chemotherapy is considered the gold standard treatment of pancreatic cancer by most guidelines. Neoadjuvant therapy (NAT) has been seen as a possible treatment option for resectable, borderline resectable and locally advanced PaC. The aim of this paper is to offer a state-of-the-art review on neoadjuvant treatments in the setting of pancreatic ductal adenocarcinoma. A systematic literature search was performed using PubMed, Cochrane, Web of Science and Embase databases, in order to identify relevant studies published up to and including July 2021 that reported and analyzed the role of neoadjuvant therapy in the setting of pancreatic carcinoma. Most authors are concordant on the strong role of neoadjuvant therapy in the setting of borderline resectable pancreatic cancers. Recent randomized trials demonstrated improvement of R0 rate and survival after NAT in this setting. Patients with locally advanced cancers may become resectable after NAT, with better results than those obtained with palliative therapies. Even in the setting of resectable cancers, NAT is being evaluated by ongoing randomized trials. Chemotherapy regimens in the setting of NAT and response to NAT are discussed. NAT has an important role in the multimodal treatment of patients with borderline resectable pancreatic cancer. It has a role in patients with locally advanced tumors as it can allow surgical resection in a relevant proportion of patients. For resectable pancreatic cancers, the role of NAT is under evaluation by several randomized trials.
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Affiliation(s)
- Jean Gugenheim
- Université Côte d'Azur, Nice, France.
- Division of Digestive Surgery and Liver Transplantation, Archet 2 Hospital, University Hospital of Nice, 151 Route de Saint-Antoine, 06200, Nice, France.
| | - Anna Crovetto
- Faculty of Medicine and Psychology, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Niccolo Petrucciani
- Faculty of Medicine and Psychology, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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13
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Evolving pancreatic cancer treatment: From diagnosis to healthcare management. Crit Rev Oncol Hematol 2021; 169:103571. [PMID: 34923121 DOI: 10.1016/j.critrevonc.2021.103571] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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14
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Birrer DL, Golcher H, Casadei R, Haile SR, Fritsch R, Hussung S, Brunner TB, Fietkau R, Meyer T, Grützmann R, Merkel S, Ricci C, Ingaldi C, Di Marco M, Guido A, Serra C, Minni F, Pestalozzi B, Petrowsky H, DeOliveira M, Bechstein WO, Bruns CJ, Oberkofler CE, Puhan M, Lesurtel M, Heinrich S, Clavien PA. Neoadjuvant Therapy for Resectable Pancreatic Cancer: A New Standard of Care. Pooled Data From 3 Randomized Controlled Trials. Ann Surg 2021; 274:713-720. [PMID: 34334656 DOI: 10.1097/sla.0000000000005126] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to pool data from randomized controlled trials (RCT) limited to resectable pancreatic ductal adenocarcinoma (PDAC) to determine whether a neoadjuvant therapy impacts on disease-free survival (DFS) and surgical outcome. SUMMARY BACKGROUND DATA Few underpowered studies have suggested benefits from neoadjuvant chemo (± radiation) for strictly resectable PDAC without offering conclusive recommendations. METHODS Three RCTs were identified comparing neoadjuvant chemo (± radio) therapy vs. upfront surgery followed by adjuvant therapy in all cases. Data were pooled targeting DFS as primary endpoint, whereas overall survival (OS), postoperative morbidity, and mortality were investigated as secondary endpoints. Survival endpoints DFS and OS were compared using Cox proportional hazards regression with study-specific baseline hazards. RESULTS A total of 130 patients were randomized (56 in the neoadjuvant and 74 in the control group). DFS was significantly longer in the neoadjuvant treatment group compared to surgery only [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.4-0.9] (P = 0.01). Furthermore, DFS for the subgroup of R0 resections was similarly longer in the neoadjuvant treated group (HR 0.6, 95% CI 0.35-0.9, P = 0.045). Although postoperative complications (Comprehensive Complication Index, CCI®) occurred less frequently (P = 0.008), patients after neoadjuvant therapy experienced a higher toxicity, but without negative impact on oncological or surgical outcome parameters. CONCLUSION Neoadjuvant therapy can be offered as an acceptable standard of care for patients with purely resectable PDAC. Future research with the advances of precision oncology should now focus on the definition of the optimal regimen.
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Affiliation(s)
- Dominique L Birrer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Henriette Golcher
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Sarah R Haile
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Ralph Fritsch
- Department of Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Saskia Hussung
- Department of Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas B Brunner
- Department of Radiation Oncology, University Hospital Magdeburg, Magdeburg, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Thomas Meyer
- Department of Surgery, Hospital Ansbach, Ansbach, Germany
| | - Robert Grützmann
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Claudio Ricci
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Mariacristina Di Marco
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy
- Medical Oncology, IRCCS Azienda Ospedaliero, University of Bologna, Bologna, Italy
| | - Alessandra Guido
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Carla Serra
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Francesco Minni
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Michelle DeOliveira
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Wolf O Bechstein
- Department of General, Visceral- and Transplantation Surgery, University Hospital Frankfurt am Main, Frankfurt, Germany
| | - Christiane J Bruns
- Department of General and Transplantation Surgery, University Hospital Cologne, Köln, Germany
| | - Christian E Oberkofler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Milo Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, University Lyon I, Lyon, France
| | - Stefan Heinrich
- Department of General, Visceral and Transplantation Surgery, University Hospital of Mainz, Mainz, Germany
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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15
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Tewari M, Swain JR, Mahendran R. Update on Management Periampullary/Pancreatic Head Cancer. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02053-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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16
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Rieser CJ, Narayanan S, Bahary N, Bartlett DL, Lee KK, Paniccia A, Smith K, Zureikat AH. Optimal management of patients with operable pancreatic head cancer: A Markov decision analysis. J Surg Oncol 2021; 124:801-809. [PMID: 34231222 DOI: 10.1002/jso.26589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/11/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Neoadjuvant therapy (NAT) is an emerging strategy for operable pancreatic ductal adenocarcinoma (PDAC). While NAT increases multimodal therapy completion, it risks functional decline and treatment dropout. We used decision analysis to determine optimal management of localized PDAC and consider risks faced by elderly patients. METHODS A Markov cohort decision analysis model evaluated treatment options for a 60-year-old patient with resectable PDAC: (1) upfront pancreaticoduodenectomy or (2) NAT. One-way and probabilistic sensitivity analyses were performed. A subanalysis considered the scenario of a 75-year-old patient. RESULTS For the base case, NAT offered an incremental survival gain of 4.6 months compared with SF (overall survival: 26.3 vs. 21.7 months). In one-way sensitivity analyses, findings were sensitive to recurrence-free survival for NAT patients undergoing adjuvant, probability of completing NAT, and probability of being resectable at exploration after NAT. On probabilistic analysis, NAT was favored in a majority of trials (97%) with a median survival benefit of 5.1 months. In altering the base case for the 75-year-old scenario, NAT had a survival benefit of 3.8 months. CONCLUSIONS This analysis demonstrates a significant benefit to NAT in patients with localized PDAC. This benefit persists even in the elderly cohort.
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Affiliation(s)
- Caroline J Rieser
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sowmya Narayanan
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David L Bartlett
- AHN Cancer Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth Smith
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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17
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Muttillo EM, Ciardi A, Saullo P, Troiano R, Masselli G, Guida M, Tortora A, Sperduti I, Marinello G, Chirletti P, Caronna R. A Prognostic Score for Predicting Survival in Patients With Pancreatic Head Adenocarcinoma and Distal Cholangiocarcinoma. In Vivo 2021; 35:507-515. [PMID: 33402503 DOI: 10.21873/invivo.12285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/28/2020] [Accepted: 11/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIM Survival of patients with pancreatic cancer remains poor despite improvements in therapeutic strategies. This study aims to create a novel preoperative score to predict prognosis in patients with tumors of the pancreaticobiliary head. PATIENTS AND METHODS Data on 190 patients who underwent to pancreaticoduodenectomy at Sapienza University of Rome from January 2010 to December 2018 were retrospectively analyzed. After exclusion criteria, 101 patients were considered eligible for retrospective study. Preoperative biological, clinical and radiological parameters were considered. RESULTS Pancreatic ductal adenocarcinoma [hazard ratio (HR)=1.995, 95% confidence intervaI (CI)=1.1-3.3; p=0.01], carbohydrate antigen 19.9 (CA 19.9) >230 U/ml (HR=2.414, 95% CI=2.4-1.5, p<0.0001) and Wirsung duct diameter >3 mm (HR=1.592, 95% CI=1.5-0.9; p=0.08) were the only parameters associated with poor prognosis. Through these parameters, a prognostic score (PHT score) was developed which predicted worst survival when exceeding 2 and better survival when ≤2. CONCLUSION The PHT score may have a potential impact on predicting overall survival and consequently modulate the timing and type of treatment (up-front surgery vs. neoadjuvant therapy) patients are offered.
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Affiliation(s)
| | - Antonio Ciardi
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Paolina Saullo
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Raffaele Troiano
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Gabriele Masselli
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Marianna Guida
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Alessandra Tortora
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - Isabella Sperduti
- Biostatistical Unit - Clinical Trials Center, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giulio Marinello
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Piero Chirletti
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Caronna
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy;
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18
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Taboada AGM, Lominchar PL, Roman LM, García-Alfonso P, Martin AJM, Rodriguez JAB, Pascual JMA. Advances in neoadjuvant therapy for resectable pancreatic cancer over the past two decades. Ann Hepatobiliary Pancreat Surg 2021; 25:179-191. [PMID: 34053920 PMCID: PMC8180394 DOI: 10.14701/ahbps.2021.25.2.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/31/2020] [Indexed: 02/06/2023] Open
Abstract
In the last two decades, pancreatic cancer has been undergoing important changes in its perioperative management due to the great interest in multidisciplinary management and preoperative multimodal therapy, which in numerous studies have shown promising clinical results. Although the standard of treatment for resectable pancreatic ductal adenocarcinoma (PDAC) today is surgery followed by adjuvant therapy, as it is a biologically aggressive disease, even with complete resection, it has high rates of local and distant relapse. Several retrospective and prospective phase I/II studies have opened the window for neoadjuvant therapy with chemotherapy (CT), chemoradiotherapy (CRT), or both, as an alternative treatment for resectable pancreatic cancer, with promising results. Neoadjuvant therapy could has some advantages, including early administration of systemic treatment, in vivo assessment of response to treatment, increase resectability rate in borderline patients, increase resection rate with negative margin and survival benefit. While it seems clear that even potentially resectable disease would benefit from preoperative multimodal therapy, the optimal neoadjuvant therapeutic strategy is still controversial and currently there are only recommendations for neoadjuvant treatment, in clinical guidelines such as the NCCN and ESMO, for borderline and/or locally advanced PDAC. This review provides an overview of recent studies available and how they relate to systemic treatment of resectable PDAC in the neoadjuvant setting.
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Affiliation(s)
- Alvaro Gregorio Morales Taboada
- Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain.,Transplant and Hepatobiliopancreatic Surgery Unit, Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pablo Lozano Lominchar
- Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain
| | - Lorena Martin Roman
- Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain
| | - Pilar García-Alfonso
- Department of Medical Oncology, Department of Oncology, Hospital general Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain
| | - Andres Jesús Muñoz Martin
- Department of Medical Oncology, Department of Oncology, Hospital general Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain
| | - Jose Antonio Blanco Rodriguez
- Department of Radiation Oncology, Department of Oncology, Hospital general Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain
| | - Jose Manuel Asencio Pascual
- Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañon, Complutense University of Madrid, Madrid, Spain.,Transplant and Hepatobiliopancreatic Surgery Unit, Department of General and Digestive Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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19
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Vitello DJ, Bentrem DJ. A review of response in neoadjuvant therapy for exocrine pancreatic cancer. J Surg Oncol 2021; 123:1449-1459. [PMID: 33831249 DOI: 10.1002/jso.26369] [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: 12/22/2020] [Accepted: 12/27/2020] [Indexed: 11/11/2022]
Abstract
Despite overall advances in cancer therapy, patients with pancreatic ductal adenocarcinoma continue to have a poor prognosis. While adjuvant therapy is still considered standard, there is mounting evidence that neoadjuvant therapy confers similar benefits in patients with locally advanced disease. The primary measures of response are radiographic, biochemical, margin status, and pathologic. Given overall low response rates and the need for new treatment strategies, standard metrics remain important to the investigation of new systemic agents.
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Affiliation(s)
- Dominic J Vitello
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David J Bentrem
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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20
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Factors Predicting Response, Perioperative Outcomes, and Survival Following Total Neoadjuvant Therapy for Borderline/Locally Advanced Pancreatic Cancer. Ann Surg 2021; 273:341-349. [PMID: 30946090 DOI: 10.1097/sla.0000000000003284] [Citation(s) in RCA: 222] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To identify predictive factors associated with operative morbidity, mortality, and survival outcomes in patients with borderline resectable (BR) or locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) undergoing total neoadjuvant therapy (TNT). BACKGROUND The optimal preoperative treatment sequencing for BR/LA PDA is unknown. TNT, or systemic chemotherapy followed by chemoradiation (CRT), addresses both occult metastases and positive margin risks and thus is a potentially optimal strategy; however, factors predictive of perioperative and survival outcomes are currently undefined. METHODS We reviewed our experience in BR/LA patients undergoing resection from 2010 to 2017 following TNT assessing operative morbidity, mortality, and survival in order to define outcome predictors and response endpoints. RESULTS One hundred ninety-four patients underwent resection after TNT, including 123 (63%) BR and 71 (37%) LA PDAC. FOLFIRINOX or gemcitabine along with nab-paclitaxel were used in 165 (85%) and 65 (34%) patients, with 36 (19%) requiring chemotherapeutic switch before long-course CRT and subsequent resection. Radiologic anatomical downstaging was uncommon (28%). En bloc venous and/or arterial resection was required in 125 (65%) patients with 94% of patients achieving R0 margins. The 90-day major morbidity and mortality was 36% and 6.7%, respectively. Excluding operative mortalities, the median, 1-year, 2-year, and 3-year recurrence-free survival (RFS) [overall survival (OS)] rates were 23.5 (58.8) months, 65 (96)%, 48 (78)%, and 32 (62)%, respectively. Radiologic downstaging, vascular resection, and chemotherapy regimen/switch were not associated with survival. Only 3 factors independently associated with prolonged survival, including extended duration (≥6 cycles) chemotherapy, optimal post-chemotherapy CA19-9 response, and major pathologic response. Patients achieving all 3 factors had superior survival outcomes with a survival detriment for each failing factor. In a subset of patients with interval metabolic (PET) imaging after initial chemotherapy, complete metabolic response highly correlated with major pathologic response. CONCLUSION Our TNT experience in resected BR/LA PDAC revealed high negative margin rates despite low radiologic downstaging. Extended duration chemotherapy with associated biochemical and pathologic responses highly predicted postoperative survival. Potential modifications of initial chemotherapy treatment include extending cycle duration to normalize CA19-9 or achieve complete metabolic response, or consideration of chemotherapeutic switch in order to achieve these factors may improve survival before moving forward with CRT and subsequent resection.
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21
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Jaidev LR, Chede LS, Kandikattu HK. Theranostic Nanoparticles for Pancreatic Cancer Treatment. Endocr Metab Immune Disord Drug Targets 2021; 21:203-214. [PMID: 32416712 DOI: 10.2174/1871530320666200516164911] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 11/22/2022]
Abstract
Pancreatic cancer is one of the low vascular permeable tumors with a high mortality rate. The five-year survival period is ~5%. The field of drug delivery is at its pace in developing unique drug delivery carriers to treat high mortality rate cancers such as pancreatic cancer. Theranostic nanoparticles are the new novel delivery carriers where the carrier is loaded with both diagnostic and therapeutic agents. The present review discusses various therapeutic and theranostic nanocarriers for pancreatic cancer.
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Affiliation(s)
- Leela R Jaidev
- College of Pharmacy, University of Iowa, 52246, Iowa, United States
| | - Laxmi S Chede
- College of Pharmacy, University of Iowa, 52246, Iowa, United States
| | - Hemanth K Kandikattu
- Department of Medicine, Tulane Eosinophilic Disorders Centre (TEDC), Section of Pulmonary Diseases, Tulane University School of Medicine, New Orleans, LA 70112, United States
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22
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Vidri RJ, Olsen WT, Clark DE, Fitzgerald TL. Upfront resection versus neoadjuvant therapy for T1/T2 pancreatic cancer. HPB (Oxford) 2021; 23:279-289. [PMID: 32698950 DOI: 10.1016/j.hpb.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of neoadjuvant therapy remains controversial for resectable pancreatic neoplasms. We evaluated treatment outcomes for T1/T2 tumors. METHODS Retrospective study of patients with T1/T2 (Stage I-II) pancreatic cancer within the NCDB. Treatment-sequence variables were used for classification: "surgery + chemotherapy" (S+C), "chemotherapy + surgery" (C+S), "surgery only" (SO), and "chemotherapy only" (CO). RESULTS 13 412 patients were included; the majority had T2 tumors. 8 490 received upfront surgery; 4 922 preoperative chemotherapy. In the surgery branch, 5 684 received surgery and chemotherapy (S+C); 2 806 did not receive chemotherapy (SO). Of those intended to receive preoperative chemotherapy, 3 804 received only chemotherapy (CO); 1 118 proceeded to surgery (C+S). Median survival for S+C and C+S groups was similar (25.9 vs 26.2) [HR 0.92, p= 0.41]. Compared to the CO group, the SO group had improved median survival (13.5 vs. 10.8) [HR 0.63, p<0.001]. Branched analyses demonstrated improved median and 5-year (20.8% vs 12.7%) survival for patients receiving upfront resection [HR 0.77, p<0.001]. CONCLUSION Patients with T1/T2 pancreatic cancer have similar survival irrespective of the timing of chemotherapy and surgery, if they receive both. Upfront resection ensures surgery is delivered, increasing the possibility of long-term survival.
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Affiliation(s)
- Roberto J Vidri
- Department of Surgery, Maine Medical Center, 887 Congress St #400, Portland, ME, 04102, USA; Department of Surgery, St. Mary's Regional Medical Center, 99 Campus Avenue, 4th Floor, Suite 401, Lewiston, ME, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | - David E Clark
- Center for Outcomes Research and Evaluation, Maine Medical Center, 509 Forest Avenue, Ste. 200, Portland, ME, 04101, USA
| | - Timothy L Fitzgerald
- Department of Surgery, Maine Medical Center, 887 Congress St #400, Portland, ME, 04102, USA; Tufts University School of Medicine, Boston, MA, USA.
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23
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Olecki EJ, Stahl KA, Torres MB, Peng JS, Dixon M, Shen C, Gusani NJ. Adjuvant Chemotherapy After Neoadjuvant Chemotherapy for Pancreatic Cancer is Associated with Improved Survival for Patients with Low-Risk Pathology. Ann Surg Oncol 2021; 28:3111-3122. [PMID: 33521899 DOI: 10.1245/s10434-020-09546-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND With limited evidence, the benefit of adjuvant chemotherapy (AT) after completion of neoadjuvant chemotherapy (NT) and surgical resection for patients with pancreatic adenocarcinoma is debated. Guidelines recommend 6 months of AT for patients receiving NT. However, the patient-derived benefit from additional AT remains unknown. METHODS The National Cancer Database from 2006 to 2015 was used to identify patients undergoing NT. The chi-square test and multivariable logistic regression were used to identify differences between those receiving only NT and those receiving NT and AT. Survival analysis using the Kaplan-Meier method and the Cox proportional hazard ratio model was applied to the entire cohort and to subgroups with differing lymph node ratios (LNRs), tumor sizes, grades, and surgical margin statuses. RESULTS Of the 3897 patients who received NT, 36.7 % received additional AT. Analysis of the entire cohort showed that associated survival was significantly improved with NT and AT compared with NT alone (hazard ratio [HR], 0.83; p < 0.001). In the subgroup analysis, the survival benefit of additional AT remained significant for those with negative nodal disease, an LNR lower than 0.15, low-grade histology, and negative margin status. Overall survival did not differ between those receiving NT only and those receiving NT and AT in the group with an LNR of 0.15 or higher, high-grade histology, and positive margins. CONCLUSION This study identified an increasing trend in the use of AT after NT and showed an associated survival benefit for subgroups with low-risk pathologic features. These results suggest that the addition of AT after NT likely beneficial for these subgroups.
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Affiliation(s)
- Elizabeth J Olecki
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Kelly A Stahl
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Madeline B Torres
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - June S Peng
- Program for Liver, Pancreas, and Foregut Tumors, Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Matthew Dixon
- Program for Liver, Pancreas, and Foregut Tumors, Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Chan Shen
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA.,Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Niraj J Gusani
- Section of Surgical Oncology, Baptist MD Anderson Cancer Center, 1301 Palm Avenue, Jacksonville, FL, 32207, USA.
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24
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Greco SH, August DA, Shah MM, Chen C, Moore DF, Masanam M, Turner AL, Jabbour SK, Javidian P, Grandhi MS, Kennedy TJ, Alexander HR, Carpizo DR, Langan RC. Neoadjuvant therapy is associated with lower margin positivity rates after Pancreaticoduodenectomy in T1 and T2 pancreatic head cancers: An analysis of the National Cancer Database. Surg Open Sci 2021; 3:22-28. [PMID: 33490937 PMCID: PMC7807160 DOI: 10.1016/j.sopen.2020.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/30/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Neoadjuvant therapy (NAT) for T1/T2 pancreatic adenocarcinoma (PDAC) prior to pancreaticoduodenectomy remains controversial. We compared positive margin rates in patients with clinical T1&T2 tumors who did and did not receive NAT. METHODS The National Cancer Database (NCDB) found clinical T1&T2 PDAC patients who underwent pancreaticoduodenectomy from 2004 to 2014. Univariate and multivariate regression determined factors associated with a positive margin and survival. RESULTS 9795 patients underwent surgery for clinical T1 or T2 pancreatic head adenocarcinoma. 8472 patients had data regarding use of neoadjuvant and adjuvant therapies; of which, 774 (9.1%) received NAT and 435 (5.1%) received both chemotherapy and radiation therapy. NAT was found to lower positive margin rates from 21.8 to 15.5% (p < 0.0001) and when radiation was added this rate dropped to 13.4%. Positive margins were associated with worse overall survival (14.9 vs. 23.9 months; HR 1.702, p < 0.0001). CONCLUSIONS NAT is associated with a reduced positive margin rate in patients with T1 and T2 tumors. These findings support ongoing and future clinical trials of NAT in T1 and T2, early stage PDAC to determine impacts on survival.
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Affiliation(s)
- Stephanie H. Greco
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
| | - David A. August
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Mihir M. Shah
- Division of Surgical Oncology, Department of Surgery, Emory University
| | - Chunxia Chen
- Biostatistics, Rutgers Cancer Institute of New, Jersey
| | - Dirk F. Moore
- Biostatistics, Rutgers Cancer Institute of New, Jersey
| | - Monika Masanam
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
| | - Amber L. Turner
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Salma K. Jabbour
- Division of Radiation Oncology, Rutgers Cancer Institute of New, Jersey
| | - Parisa Javidian
- Department of Pathology, Rutgers Robert Wood Johnson University Hospital
| | - Miral S. Grandhi
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Timothy J. Kennedy
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - H. Richard Alexander
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Darren R. Carpizo
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
| | - Russell C. Langan
- Gastrointestinal and Hepatobiliary Oncology, Rutgers Cancer Institute of New, Jersey
- Department of Surgery, Rutgers Robert Wood Johnson University Medical School
- Department of Surgery, RWJBarnabas Health, Saint Barnabas Medical Center
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25
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Krell RW, McNeil LR, Yanala UR, Are C, Reames BN. Neoadjuvant Therapy for Pancreatic Ductal Adenocarcinoma: Propensity-Matched Analysis of Postoperative Complications Using ACS-NSQIP. Ann Surg Oncol 2021; 28:3810-3822. [PMID: 33386542 DOI: 10.1245/s10434-020-09460-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/23/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND The use of neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) is increasing. While there is an association between NAT and improved post-pancreatectomy complication rates in limited patient populations, the strength of the relationship and its applicability to a broader and modern pancreatectomy cohort remains unclear. METHODS We used the 2014-2018 American College of Surgeons National Surgical Quality Improvement Project to evaluate NAT use for PDAC patients undergoing pancreatectomy. We also used propensity score matching techniques to compare 30-day postoperative outcomes, including clinically relevant postoperative pancreatic fistula (CR-POPF) and delayed gastric emptying (DGE), between patients selected for NAT versus upfront surgery. RESULTS Patients receiving NAT were more likely to undergo vascular resections (33% vs. 16%, p < 0.001), have perioperative transfusions (18% vs. 12%, p < 0.001), and undergo longer procedures. Rates of CR-POPF (6%, vs. 10%, p < 0.001), DGE (11% vs. 13%, p = 0.016), postoperative percutaneous drainage (9% vs. 12%, p < 0.001), and SSI (15% vs. 18%, p < 0.001) were lower for patients selected for NAT. The association of NAT with CR-POPF remained statistically significant (adjusted odds ratio 0.52, 95% CI 0.42-0.66) after adjustment for operative technique, gland texture, and need for vascular resection for patients undergoing pancreaticoduodenectomy, but not for patients undergoing distal pancreatectomy. CONCLUSIONS Among PDAC patients undergoing resection, selection for NAT is associated with fewer CR-POPFs, postoperative procedural interventions, and infectious complications, particularly for patients undergoing pancreaticoduodenectomy. These associations should be considered in discussions of multidisciplinary treatment sequencing for patients with PDAC.
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Affiliation(s)
- Robert W Krell
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Logan R McNeil
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ujwal R Yanala
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Chandrakanth Are
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Bradley N Reames
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
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26
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Yasuta S, Kobayashi T, Aizawa H, Takahashi S, Ikeda M, Konishi M, Kojima M, Kuno H, Uesaka K, Morinaga S, Miyamoto A, Toyama H, Takakura N, Sugimachi K, Takayama W. Relationship between surgical R0 resectability and findings of peripancreatic vascular invasion on CT imaging after neoadjuvant S-1 and concurrent radiotherapy in patients with borderline resectable pancreatic cancer. BMC Cancer 2020; 20:1184. [PMID: 33267820 PMCID: PMC7709301 DOI: 10.1186/s12885-020-07698-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/26/2020] [Indexed: 12/23/2022] Open
Abstract
Background Borderline resectable pancreatic cancer (BRPC) is frequently associated with positive surgical margins and a poor prognosis because the tumor is in contact with major vessels. This study evaluated the relationship between the margin-negative (R0) resection rate and findings indicating peripancreatic vascular invasion on multidetector computed tomography (MDCT) imaging after neoadjuvant chemoradiotherapy (NACRT) in patients with BRPC. Methods Twenty-nine BRPC patients who underwent laparotomy after neoadjuvant S-1 with concurrent radiotherapy were studied retrospectively. Peripancreatic major vessel invasion was evaluated based on the length of tumor-vessel contact on MDCT. The R0 resection rates were compared between the progression of vascular invasion (PVI) group and the non-progression of vascular invasion (NVI) group. Results There were 3 patients with partial responses (10%), 25 with stable disease (86%), and 1 with progressive disease (3%) according to the RECISTv1.1 criteria. Regarding vascular invasion, 9 patients (31%) were classified as having PVI, and 20 patients (69%) were classified as having NVI. Of the 29 patients, 27 (93%) received an R0 resection, and all the PVI patients received an R0 resection (9/9; R0 resection rate = 100%) while 90% (18/20) of the NVI patients underwent an R0 resection. The exact 95% confidence interval of risk difference between those R0 resection rates was − 10.0% [− 31.7–20.4%]. Conclusions Patients with BRPC after NACRT achieved high R0 resection rates regardless of the vascular invasion status. BRPC patients can undergo R0 resections unless progressive disease is observed after NACRT. Trial registration UMIN-CTR, UMIN000009172. Registered 23 October 2012
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Affiliation(s)
- Sho Yasuta
- Department of Hepato-biliary Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Tatsushi Kobayashi
- Department of Diagnostic Radiology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Hidetoshi Aizawa
- Department of Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shinichiro Takahashi
- Department of Hepato-biliary Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masafumi Ikeda
- Department of Hepato-biliary Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masaru Konishi
- Department of Hepato-biliary Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Motohiro Kojima
- Division of Pathology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hirofumi Kuno
- Department of Diagnostic Radiology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Katsuhiko Uesaka
- Department of Hepato-biliary Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Soichiro Morinaga
- Department of Hepato-Biliary and Pancreatic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Atsushi Miyamoto
- Department of Hepato-Biliary-Pancreatic Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Hirochika Toyama
- Department of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Keishi Sugimachi
- Department of Hepato-Biliary-Pancreatic Surgery, National Hospital Organization Kyusyu Cancer Center, Fukuoka, Japan
| | - Wataru Takayama
- Department of Hepato-Biliary-Pancreatic Surgery, Chiba Cancer Center, Chiba, Japan
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27
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Le VH, O'Connor VV, Li D, Melstrom LG, Fong Y, DiFronzo AL. Outcomes of neoadjuvant therapy for cholangiocarcinoma: A review of existing evidence assessing treatment response and R0 resection rate. J Surg Oncol 2020; 123:164-171. [PMID: 32974932 DOI: 10.1002/jso.26230] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/03/2020] [Accepted: 09/05/2020] [Indexed: 12/15/2022]
Abstract
Adjuvant chemotherapy for cholangiocarcinoma (CCA) has not been shown to gain significant improvements in survival. Factors contributing to suboptimal treatment response include aggressive disease biology and late clinical presentation. When feasible, surgical resection is the first line of treatment. Yet, recurrence remains high and long-term survival is rare. Neoadjuvant therapy is an appealing approach, with oncologic advantages in allowing the treatment of occult systemic disease and selection of patients most likely to benefit from radical surgery. However, given the surgery-first treatment paradigm for CCA, there is a paucity of data supporting neoadjuvant therapy. This review summarizes the current evidence on treatment response and margin-negative (R0) resection rate associated with neoadjuvant therapy for CCA.
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Affiliation(s)
- Viet H Le
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Victoria V O'Connor
- Department of Surgery, Kaiser Permanente - Los Angeles Medical Center, Los Angeles, California, USA
| | - Daneng Li
- Department of Medical Oncology and Therapeutic Research, City of Hope National Medical Center, Duarte, California, USA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Andrew L DiFronzo
- Department of Surgery, Kaiser Permanente - Los Angeles Medical Center, Los Angeles, California, USA
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28
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Krepline AN, Geurts JL, George B, Kamgar M, Madhavan S, Erickson BA, Hall WA, Griffin MO, Evans DB, Tsai S, Kim RY. Cost-effectiveness analysis of universal germline testing for patients with pancreatic cancer. Surgery 2020; 169:629-635. [PMID: 32826069 DOI: 10.1016/j.surg.2020.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/08/2020] [Accepted: 06/24/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Historically, germline testing of patients with pancreatic cancer was performed selectively in patients with a strong family history of cancer. Current guidelines recommend universal testing because some patients may have actionable germline pathogenic variants without family history. METHODS We conducted a cost-effectiveness analysis using a decision-tree model to compare universal versus selective testing strategies for patients with pancreatic cancer. Costs, probabilities, and overall survival were estimated from the published literature and institutional data. One-way and probabilistic sensitivity analyses explored model uncertainty. RESULTS Universal germline genetic testing had an incremental cost of $310 with an increase of 0.003 life-years. The incremental cost-effectiveness ratio was $121,924/life-years. Parameters which were most impactful (sensitivity analysis) included the median overall survival of patients with advanced disease treated with personalized therapy, cost of personalized therapy for advanced disease, and the probability of receiving personalized therapy in advanced disease. A strategy of selective testing was more cost-effective in 59% of iterations when the willingness-to-pay threshold was set to $100,000/life-years. CONCLUSION Our model suggested that selective germline testing of patients with newly diagnosed pancreatic cancer is more cost-effective than universal testing. Additional research is needed to explore the impact of cascade testing of relatives on cost-effectiveness.
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Affiliation(s)
- Ashley N Krepline
- Department of Surgery, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Jennifer L Geurts
- Department of Surgery, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Ben George
- Medicine, Division of Hematology and Oncology, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Mandana Kamgar
- Medicine, Division of Hematology and Oncology, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Srivats Madhavan
- Medicine, Division of Gastroenterology and Hepatology, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Beth A Erickson
- Department of Surgery, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI; Radiation Oncology, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - William A Hall
- Department of Surgery, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI; Radiation Oncology, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Michael O Griffin
- Radiology, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Douglas B Evans
- Department of Surgery, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Susan Tsai
- Department of Surgery, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Rebecca Y Kim
- Department of Surgery, Mary Anne and Charles LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI.
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29
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Motoi F, Unno M. Adjuvant and neoadjuvant treatment for pancreatic adenocarcinoma. Jpn J Clin Oncol 2020; 50:483-489. [PMID: 32083290 DOI: 10.1093/jjco/hyaa018] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/21/2020] [Accepted: 01/28/2020] [Indexed: 02/06/2023] Open
Abstract
The prognosis of pancreatic adenocarcinoma is dismal. Hence, advances in multidisciplinary treatment strategies, including surgery, are urgently needed. Early recurrence of distant organ metastases suggests that there are occult metastases even in cases with resectable disease. Several randomized controlled trials on adjuvant chemotherapy have been conducted to prolong survival after resection. CONKO-001 study was the first to demonstrate significant improvement in disease-free survival after surgery with gemcitabine administration. The JASPAC-01 study showed the superiority of adjuvant S1 over gemcitabine in survival after resection. Based on the results, adjuvant S1 therapy is the prescribed standard of care in Japan. Recently, the PRODIGE 24/CCTG PA.6 study showed that survival of patients treated with a modified FOLFIRINOX regimen as adjuvant therapy was significantly longer than those treated with adjuvant gemcitabine therapy. Although the evidence from these trials on adjuvant chemotherapy have been the gold-standard treatment for curatively resected and fully recovered patients, resectable disease at diagnosis is not the status, resected disease after curative resection. Currently, neoadjuvant therapy is considered to be a promising alternative to surgery for pancreatic cancer. Although there are many reports regarding neoadjuvant chemoradiotherapy, so far there has been no solid evidence proving the advantage of this strategy versus standard up-front surgery. Newly obtained results from the Prep-02/JSAP05 randomized phase II/III study, comparing neoadjuvant therapy with up-front surgery, revealed significant improvement in overall survival with neoadjuvant chemotherapy by intention-to-treat analysis. Thus, neoadjuvant intervention might become a new standard strategy in cases undergoing planned resection for pancreatic cancer.
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Affiliation(s)
- Fuyuhiko Motoi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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30
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Kizy S, Altman AM, Wirth KM, Marmor S, Hui JYC, Tuttle TM, Lou E, Amin K, Denbo JW, Jensen EH. Systemic therapy without radiation may be appropriate as neoadjuvant therapy for localized pancreas cancer. Hepatobiliary Surg Nutr 2020; 9:296-303. [PMID: 32509815 PMCID: PMC7262615 DOI: 10.21037/hbsn.2019.04.17] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The utility of neoadjuvant treatment for resectable pancreas cancer is yet to be determined, but has commonly included chemoradiation. We evaluated outcomes in patients with radiographically resectable pancreatic adenocarcinoma treated with neoadjuvant chemotherapy without chemoradiation. METHODS A retrospective review of patients in our institutional pancreatic cancer registry was performed, which identified 36 patients who received neoadjuvant chemotherapy alone for resectable pancreatic adenocarcinoma between 2012 and 2016. RESULTS Median age at diagnosis was 66.3 years. Chemotherapy regimens included gemcitabine (n=17), gemcitabine/nab-paclitaxel (n=8), or 5-FU/leucovorin/irinotecan/oxaliplatin (FOLFIRINOX) (n=11). Surgical resection was performed in 69% of patients (n=25), with an R0 resection rate of 92% (n=23 patients). During chemotherapy, distant disease became apparent in 19% of patients (n=7), while no patients had evidence of local progression. Resection rates were similar between chemotherapy regimens (single agent =59%, multiple agent =79%). Median overall survival for all patients who received neoadjuvant chemotherapy was 30.3 and 34.4 months for those who underwent surgical resection. There was no difference in median survival for patients treated with gemcitabine (31.3 months) or multi-agent chemotherapy (29.7 months). CONCLUSIONS A short course of neoadjuvant chemotherapy without chemoradiation may improve patient selection prior to surgical resection for pancreas cancer. Further, local disease progression did not limit surgical resection in this small series.
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Affiliation(s)
- Scott Kizy
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Ariella M. Altman
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Keith M. Wirth
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Schelomo Marmor
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Jane Y. C. Hui
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Todd M. Tuttle
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Emil Lou
- Division of Hematology and Oncology, Department of Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Khalid Amin
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Jason W. Denbo
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Eric H. Jensen
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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31
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Yokose T, Kitago M, Matsusaka Y, Masugi Y, Shinoda M, Yagi H, Abe Y, Oshima G, Hori S, Endo Y, Toyama K, Iwabuchi Y, Takemura R, Ishii R, Nakahara T, Okuda S, Jinzaki M, Kitagawa Y. Usefulness of 18 F-fluorodeoxyglucose positron emission tomography/computed tomography for predicting the prognosis and treatment response of neoadjuvant therapy for pancreatic ductal adenocarcinoma. Cancer Med 2020; 9:4059-4068. [PMID: 32281301 PMCID: PMC7300404 DOI: 10.1002/cam4.3044] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/20/2020] [Accepted: 03/21/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The Response Evaluation Criteria in Solid Tumors (RECIST) for computed tomography (CT) is preoperatively used to evaluate therapeutic effects. However, it does not reflect the pathological treatment response (PTR) of pancreatic ductal adenocarcinoma (PDAC). The Positron Emission Tomography Response Criteria in Solid Tumors (PERCIST) for positron emission tomography (PET)/CT is effective in other cancers. This study aimed to confirm the usefulness of PERCIST and the prognostic utility of PET/CT for PDAC. METHODS Forty-two consecutive patients with PDAC who underwent neoadjuvant therapy (NAT) and pancreatectomy at our institution between 2014 and 2018 were retrospectively analyzed. We evaluated the treatment response and prognostic significance of PET/CT parameters and other clinicopathological factors. RESULTS Twenty-two patients who underwent PET/CT both before and after NAT with the same protocol were included. RECIST revealed stable disease and partial response in 20 and 2 cases, respectively. PERCIST revealed stable metabolic disease, partial metabolic response, and complete metabolic response in 8, 9, and 5 cases, respectively. The PTR was G3, G2, and G1 in 8, 12, and 2 cases, respectively. For comparing the concordance rates between PTR and each parameter, PERCIST (72.7% [16/22]) was significantly superior to RECIST (36.4% [8/22]) (P = .017). The area under the curve survival values of PET/CT parameters were 0.777 for metabolic tumor volume (MTV), 0.500 for maximum standardized uptake value, 0.554 for peak standardized uptake value corrected for lean body mass, and 0.634 for total lesion glycolysis. A 50% cut-off value for the MTV reduction rate yielded the largest difference in survival between responders and nonresponders. On multivariate analysis, MTV reduction rates < 50% were independent predictors for relapse-free survival (hazard ratio [HR], 3.92; P = .044) and overall survival (HR, 14.08; P = .023). CONCLUSIONS PERCIST was more accurate in determining NAT's therapeutic effects for PDAC than RECIST. MTV reduction rates were independent prognostic factors for PDAC.
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Affiliation(s)
- Takahiro Yokose
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Minoru Kitago
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Yohji Matsusaka
- Department of RadiologyKeio University School of MedicineTokyoJapan
| | - Yohei Masugi
- Department of PathologyKeio University School of MedicineTokyoJapan
| | - Masahiro Shinoda
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Hiroshi Yagi
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Yuta Abe
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Go Oshima
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Shutaro Hori
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Yutaka Endo
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Kenji Toyama
- Department of RadiologyKeio University School of MedicineTokyoJapan
| | - Yu Iwabuchi
- Department of RadiologyKeio University School of MedicineTokyoJapan
| | - Ryo Takemura
- Biostatistics Unit, Clinical and Translational Research CenterKeio University HospitalTokyoJapan
| | - Ryota Ishii
- Biostatistics Unit, Clinical and Translational Research CenterKeio University HospitalTokyoJapan
| | - Tadaki Nakahara
- Department of RadiologyKeio University School of MedicineTokyoJapan
| | - Shigeo Okuda
- Department of RadiologyKeio University School of MedicineTokyoJapan
| | - Masahiro Jinzaki
- Department of RadiologyKeio University School of MedicineTokyoJapan
| | - Yuko Kitagawa
- Department of SurgeryKeio University School of MedicineTokyoJapan
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32
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Gamboa AC, Rupji M, Switchenko JM, Lee RM, Turgeon MK, Meyer BI, Russell MC, Cardona K, Kooby DA, Maithel SK, Shah MM. Optimal timing and treatment strategy for pancreatic cancer. J Surg Oncol 2020; 122:457-468. [PMID: 32470166 DOI: 10.1002/jso.25976] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND For pancreatic adenocarcinoma (PDAC), no studies have established any association between earlier treatment initiation and long-term outcomes. In addition, an optimal type of initial treatment for the localized disease remains ill-defined. METHODS Patients in the National Cancer Database (2004-2015) with clinical stage I (CS-I) and II (CS-II) PDAC who underwent curative-intent resection were included. Optimal time from diagnosis-to-treatment including neoadjuvant chemotherapy, neoadjuvant chemoradiation, or upfront surgery was assessed. An optimal type of treatment was evaluated. The primary outcome was overall survival (OS). RESULTS Among 29 167 patients, starting any treatment within 0 to 6 weeks was associated with improved median OS compared with 7 to 12 weeks (21.0 vs 20.1 months; P = .004). This persisted when accounting for sex, race, and Charlson-Deyo score (hazard ratio [HR], 0.94; P = 0.02) and on subset analysis for CS-I (23.5 vs 21.8 months; P = .04) and CS-II (19.4 vs 18.3 months; P = .03). Neoadjuvant chemotherapy was associated with improved OS compared with neoadjuvant chemoradiation (25.6 vs 22.7 months; P < .0001) or US (25.6 vs 20.1 months; P < .0001) even when accounting for sex, race, and Charlson-Deyo score (neoadjuvant chemoradiation: HR, 0.86; P < .001; US: HR, 0.79; P < .001). This improvement persisted in subset analysis with NC compared with neoadjuvant chemoradiation (CS-I: 28.6 vs 25.0 months; CS-II: 25.0 vs 22.9 months; both P < .0001) and to US (CS-I: 28.6 vs 22.9 months; CS-II: 24.7 vs 18.4 months; both P < .0001). On multivariable analysis for each CS-I/CS-II, NC remained associated with 20% improved survival compared with neoadjuvant chemoradiation or upfront surgery. CONCLUSIONS For PDAC, initiation of therapy within 6 weeks from diagnosis is associated with improved survival, with neoadjuvant chemotherapy associated with the best survival compared with neoadjuvant chemoradiation or upfront surgery.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Manali Rupji
- Bioinformatics and Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rachel M Lee
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Michael K Turgeon
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Benjamin I Meyer
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C Russell
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David A Kooby
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mihir M Shah
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Motoi F, Unno M. Neoadjuvant treatment for resectable pancreatic adenocarcinoma: What is the best protocol? Ann Gastroenterol Surg 2020; 4:100-108. [PMID: 32258974 PMCID: PMC7105839 DOI: 10.1002/ags3.12311] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/27/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Abstract
Although upfront surgery has been the gold standard for pancreatic adenocarcinoma that is planned for resection, it should be compared with the alternative strategy of neoadjuvant therapy. Despite the many reports of the efficacy of neoadjuvant therapy, most of them were not comparative. Recently Prep-02/JSAP05 study clearly demonstrated the significant survival benefit of neoadjuvant chemotherapy over upfront surgery for pancreatic adenocarcinoma that is planned for resection. These findings opened a new chapter of neoadjuvant therapy. Ongoing trials are expected to confirm the evidence. This review summarizes the past, present, and future perspectives of neoadjuvant therapy and its optimization.
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Affiliation(s)
- Fuyuhiko Motoi
- Department of SurgeryTohoku University Graduate School of MedicineAoba‐kuJapan
| | - Michiaki Unno
- Department of SurgeryTohoku University Graduate School of MedicineAoba‐kuJapan
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Barbour AP, Samra JS, Haghighi KS, Donoghoe MW, Burge M, Harris MT, Chua YJ, Mitchell J, O'Rourke N, Chan H, Gebski VJ, Gananadha S, Croagh DG, Kench JG, Goldstein D. The AGITG GAP Study: A Phase II Study of Perioperative Gemcitabine and Nab-Paclitaxel for Resectable Pancreas Cancer. Ann Surg Oncol 2020; 27:2506-2515. [PMID: 31997125 DOI: 10.1245/s10434-020-08205-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND While combination therapy with nab-paclitaxel/gemcitabine (nab-gem) is effective in pancreatic ductal adenocarcinoma (PDAC), its efficacy as perioperative chemotherapy is unknown. The primary objective of this multicenter, prospective, single-arm, phase II study was to determine whether neoadjuvant therapy with nab-gem was associated with higher complete resection rates (R0) in resectable PDAC, while the secondary objectives were to determine the utility of radiological assessment of response to preoperative chemotherapy and the safety and efficacy of nab-gem as perioperative therapy. METHODS Patients were recruited from eight Australian sites, and 42 patients with radiologically defined resectable PDAC and an Eastern Cooperative Oncology Group performance status of 0-2 were enrolled. Participants received two cycles of preoperative nab-paclitaxel 125 mg/m2 and gemcitabine 1000 mg/m2 on days 1, 8, and 15 (28-day cycle) presurgery, and four cycles postoperatively. Early response to chemotherapy was measured with fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) scans on day 15. RESULTS Preoperative nab-gem was completed by 93% of participants, but only 63% postoperatively. Thirty-six patients had surgery: 6 (17%) were unresectable, 15 (52%) had R0 (≥ 1 mm) resections, 14 (48%) had R1 (< 1 mm) resections, and 1 patient did not have PDAC. Median progression-free survival was 12.3 months and median overall survival (OS) was 23.5 months: R0 patients had an OS of 35 months versus 25.6 months for R1 patients after surgery. Seven patients had not progressed after 43 months. CONCLUSIONS The GAP trial demonstrated that perioperative nab-gem was tolerable. Although the primary endpoint of an 85% R0 rate was not met, the R0 rate was similar to trials using a > 1 mm R0 resection definition, and survival rates were comparable with recent adjuvant studies.
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Affiliation(s)
- Andrew P Barbour
- Princess Alexandra Hospital, Brisbane, QLD, Australia. .,The University of Queensland, Brisbane, QLD, Australia.
| | | | | | - Mark W Donoghoe
- National Health and Medical Research Council Clinical Trials Centre, Sydney, NSW, Australia.,Stats Central, University of NSW, Sydney, NSW, Australia
| | - Matthew Burge
- The University of Queensland, Brisbane, QLD, Australia.,Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | | | - Yu Jo Chua
- The Canberra Hospital, Woden, ACT, Australia
| | - Jenna Mitchell
- National Health and Medical Research Council Clinical Trials Centre, Sydney, NSW, Australia
| | - Nick O'Rourke
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | | | - Val J Gebski
- National Health and Medical Research Council Clinical Trials Centre, Sydney, NSW, Australia
| | - Sivakumar Gananadha
- The Canberra Hospital, Woden, ACT, Australia.,Australian National University, Canberra, ACT, Australia
| | - Daniel G Croagh
- Monash Medical Centre, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - James G Kench
- Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, University of Sydney, Sydney, NSW, Australia
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35
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Hank T, Sandini M, Ferrone CR, Rodrigues C, Weniger M, Qadan M, Warshaw AL, Lillemoe KD, Fernández-del Castillo C. Association Between Pancreatic Fistula and Long-term Survival in the Era of Neoadjuvant Chemotherapy. JAMA Surg 2019; 154:943-951. [PMID: 31411659 PMCID: PMC6694396 DOI: 10.1001/jamasurg.2019.2272] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/17/2019] [Indexed: 01/05/2023]
Abstract
Importance In the past decade, the use of neoadjuvant therapy (NAT) has increased for patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC). Data on pancreatic fistula and related overall survival (OS) in this setting are limited. Objective To compare postoperative complications in patients undergoing either upfront resection or pancreatectomy following NAT, focusing on clinically relevant postoperative pancreatic fistula (CR-POPF) and potential associations with OS. Design, Setting, and Participants This retrospective cohort study was conducted on data from patients who underwent pancreatic resection for PDAC at the Massachusetts General Hospital from January 1, 2007, to December 31, 2017. Exposures Pancreatic cancer surgery with or without NAT. Main Outcomes and Measures Overall morbidity and CR-POPF rates were compared between NAT and upfront resection. Factors associated with CR-POPF were assessed with univariate and multivariate analysis. Survival data were analyzed by Kaplan-Meier curves and a Cox proportional hazards regression model. Results Of 753 patients, 364 were men (48.3%); median (interquartile range) age was 68 (61-75) years. A total of 346 patients (45.9%) received NAT and 407 patients (54.1%) underwent upfront resection. At pathologic examination, NAT was associated with smaller tumor size (mean [SD], 26.0 [15.3] mm vs 32.7 [14.4] mm; P < .001), reduced nodal involvement (102 [25.1%] vs 191 [55.2%]; P < .001), and higher R0 rates (257 [74.3%] vs 239 [58.7%]; P < .001). There were no significant differences in severe complication rate or 90-day mortality. The rate of CR-POPF was 3.6-fold lower in patients receiving NAT vs upfront resection (13 [3.8%] vs 56 [13.8%]; P < .001). In addition, factors associated with CR-POPF changed after NAT, and only soft pancreatic texture was associated with a higher risk of CR-POPF (38.5% vs 6.3%; P < .001). Survival analysis showed no differences between patients with or without CR-POPF after upfront resection (26 vs 25 months; P = .66), but after NAT, a worse overall survival rate was observed in patients with CR-POPF (17 vs 34 months; P = .002). This association was independent of other established predictors of overall survival by multivariate analysis (hazard ratio, 2.80; 95% CI, 1.44-5.45; P < .002). Conclusions and Relevance Neoadjuvant therapy may be associated with a significant reduction in the rate of CR-POPF. In addition, standard factors associated with CR-POPF appear to be no longer applicable following NAT. However, once CR-POPF occurs, it is associated with a significant reduction in long-term survival. Patients with CR-POPF may require closer follow-up and could benefit from additional therapy.
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Affiliation(s)
- Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marta Sandini
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Cristina R. Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Clifton Rodrigues
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Maximilian Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew L. Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Keith D. Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Brunner M, Wu Z, Krautz C, Pilarsky C, Grützmann R, Weber GF. Current Clinical Strategies of Pancreatic Cancer Treatment and Open Molecular Questions. Int J Mol Sci 2019; 20:ijms20184543. [PMID: 31540286 PMCID: PMC6770743 DOI: 10.3390/ijms20184543] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 12/24/2022] Open
Abstract
Pancreatic cancer is one of the most lethal malignancies and is associated with a poor prognosis. Surgery is considered the only potential curative treatment for pancreatic cancer, followed by adjuvant chemotherapy, but surgery is reserved for the minority of patients with non-metastatic resectable tumors. In the future, neoadjuvant treatment strategies based on molecular testing of tumor biopsies may increase the amount of patients becoming eligible for surgery. In the context of non-metastatic disease, patients with resectable or borderline resectable pancreatic carcinoma might benefit from neoadjuvant chemo- or chemoradiotherapy followed by surgeryPatients with locally advanced or (oligo-/poly-)metastatic tumors presenting significant response to (neoadjuvant) chemotherapy should undergo surgery if R0 resection seems to be achievable. New immunotherapeutic strategies to induce potent immune response to the tumors and investigation in molecular mechanisms driving tumorigenesis of pancreatic cancer may provide novel therapeutic opportunities in patients with pancreatic carcinoma and help patient selection for optimal treatment.
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Affiliation(s)
- Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
| | - Zhiyuan Wu
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
| | - Christian Pilarsky
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich Alexander University, Krankenhausstraße 12, 91054 Erlangen, Germany.
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37
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Mehtsun WT, Hashimoto DA, Ferrone CR. Status of 5-Year Survivors of the Whipple Procedure for Pancreatic Adenocarcinoma. Adv Surg 2019; 53:253-269. [PMID: 31327451 DOI: 10.1016/j.yasu.2019.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Winta T Mehtsun
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WAC 460, Boston, MA 02114, USA
| | - Daniel A Hashimoto
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WAC 460, Boston, MA 02114, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WAC 460, Boston, MA 02114, USA.
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38
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Wei AC, Ou FS, Shi Q, Carrero X, O'Reilly EM, Meyerhardt J, Wolff RA, Kindler HL, Evans DB, Deshpande V, Misdraji J, Tamm E, Sahani D, Moore M, Newman E, Merchant N, Berlin J, Goff LW, Pisters P, Posner MC. Perioperative Gemcitabine + Erlotinib Plus Pancreaticoduodenectomy for Resectable Pancreatic Adenocarcinoma: ACOSOG Z5041 (Alliance) Phase II Trial. Ann Surg Oncol 2019; 26:4489-4497. [PMID: 31418130 DOI: 10.1245/s10434-019-07685-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is considerable interest in a neoadjuvant approach for resectable pancreatic ductal adenocarcinoma (PDAC). This study evaluated perioperative gemcitabine + erlotinib (G+E) for resectable PDAC. METHODS A multicenter, cooperative group, single-arm, phase II trial was conducted between April 2009 and November 2013 (ACOSOG Z5041). Patients with biopsy-confirmed PDAC in the pancreatic head without evidence of involvement of major mesenteric vessels (resectable) were eligible. Patients (n = 123) received an 8-week cycle of G+E before and after surgery. The primary endpoint was 2-year overall survival (OS), and secondary endpoints included toxicity, response, resection rate, and time to progression. Resectability was assessed retrospectively by central review. The study closed early due to slow accrual, and no formal hypothesis testing was performed. RESULTS Overall, 114 patients were eligible, consented, and initiated protocol treatment. By central radiologic review, 97 (85%) of the 114 patients met the protocol-defined resectability criteria. Grade 3+ toxicity was reported in 60% and 79% of patients during the neoadjuvant phase and overall, respectively. Twenty-two of 114 (19%) patients did not proceed to surgery; 83 patients (73%) were successfully resected. R0 and R1 margins were obtained in 67 (81%) and 16 (19%) resected patients, respectively, and 54 patients completed postoperative G+E (65%). The 2-year OS rate for the entire cohort (n = 114) was 40% (95% confidence interval [CI] 31-50), with a median OS of 21.3 months (95% CI 17.2-25.9). The 2-year OS rate for resected patients (n = 83) was 52% (95% CI 41-63), with a median OS of 25.4 months (95% CI 21.8-29.6). CONCLUSIONS For resectable PDAC, perioperative G+E is feasible. Further evaluation of neoadjuvant strategies in resectable PDAC is warranted with more active systemic regimens.
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Affiliation(s)
- Alice C Wei
- University Health Network-Princess Margaret Hospital, Toronto, ON, Canada. .,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Fang-Shu Ou
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | - Qian Shi
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | - Xiomara Carrero
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Hedy L Kindler
- University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | | | | | - Joseph Misdraji
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Eric Tamm
- MD Anderson Cancer Center, Houston, TX, USA
| | - Dushyant Sahani
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Malcolm Moore
- University Health Network-Princess Margaret Hospital, Toronto, ON, Canada
| | - Elliot Newman
- New York University Langone Medical Center, New York, NY, USA
| | - Nipun Merchant
- University of Miami Miller School of Medicine-Sylvester Cancer Center, Miami, FL, USA
| | - Jordan Berlin
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura W Goff
- Vanderbilt University Medical Center, Nashville, TN, USA
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Altman AM, Wirth K, Marmor S, Lou E, Chang K, Hui JYC, Tuttle TM, Jensen EH, Denbo JW. Completion of Adjuvant Chemotherapy After Upfront Surgical Resection for Pancreatic Cancer Is Uncommon Yet Associated With Improved Survival. Ann Surg Oncol 2019; 26:4108-4116. [PMID: 31313044 DOI: 10.1245/s10434-019-07602-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Multiple trials have demonstrated a survival benefit for adjuvant chemotherapy after resection of pancreatic adenocarcinoma. This study aimed to identify the rate for completion of adjuvant chemotherapy, factors associated with completion, and its impact on survival after surgical resection. METHODS The Surveillance Epidemiology and End Results Medicare-linked data was used to identify patients who underwent upfront resection for pancreatic adenocarcinoma from 2004 to 2013. Billing codes were used to quantify receipt and completion of chemotherapy. Factors associated with completion of chemotherapy were identified using multivariable regression. Kaplan-Meier and Cox proportional-hazards modeling were used to examine survival. RESULTS The inclusion criteria were met by 2440 patients. Of these patients, 65% received no adjuvant chemotherapy, 28% received incomplete therapy, and 7% completed chemotherapy. The factors associated with chemotherapy completion were nodal metastases and treatment at a National Cancer Institute-designated cancer center (p ≤ 0.05). Comorbidities decreased the odds of completion (p ≤ 0.05). The median overall survival (OS) was 14 months for the patients who received no adjuvant chemotherapy, 17 months for those who received incomplete adjuvant chemotherapy, and 22 months for those who completed adjuvant chemotherapy (p ≤ 0.05). More recent diagnosis, comorbidities, T stage, nodal metastases, and no adjuvant chemotherapy were associated with an increased hazard ratio for death (p ≤ 0.05). Evaluation of 15 or more nodes and completion of chemotherapy decreased the hazard ratio for death (p ≤ 0.05). CONCLUSIONS Only 7% of the Medicare patients who underwent upfront resection for pancreatic cancer completed adjuvant chemotherapy, yet completion of adjuvant chemotherapy was associated with improved OS. Completion of adjuvant chemotherapy should be the goal after upfront resection, but neoadjuvant chemotherapy may ensure that patients receive systemic chemotherapy.
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Affiliation(s)
- Ariella M Altman
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Keith Wirth
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Schelomo Marmor
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Emil Lou
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Katherine Chang
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jane Y C Hui
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Todd M Tuttle
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Eric H Jensen
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jason W Denbo
- Division of Surgical Oncology, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA. .,Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
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40
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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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A Preoperative Prognostic Scoring System to Predict Prognosis for Resectable Pancreatic Cancer: Who Will Benefit from Upfront Surgery? J Gastrointest Surg 2019; 23:990-996. [PMID: 30242645 DOI: 10.1007/s11605-018-3972-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/10/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Upfront surgery is recommended in patients with potentially resectable pancreatic ductal adenocarcinoma (R-PDAC) by National Comprehensive Center Network (NCCN) guidelines. However, even among R-PDACs, there is a subset that demonstrates extremely poor prognosis. The purpose of this study was to identify preoperative prognostic factors for upfront surgical resection of R-PDACs. METHODS The records of 278 consecutive patients with PDAC who underwent curative resection between 2001 and 2015 in a single institution were retrospectively reviewed. Preoperative factors to predict prognosis in patients with R-PDAC according to the NCCN guidelines were analyzed. RESULTS Of the 278 patients who underwent resection, 153 R-PDACs received upfront surgery with a median survival time (MST) of 26.4 months. Tumor location (pancreatic head) (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.14-3.40; P = 0.015), preoperative cancer antigen 19-9 (CA19-9) > 100 U/mL (OR 1.92, 1.31-2.80; P = 0.0009), and tumor size > 20 mm (OR 1.50, 1.02-2.19; P = 0.038) were identified as preoperative independent predictive risk factors for poor prognosis in patients with R-PDACs. In the patients with R-PDAC, 5-year survival was 60.7%, 21.5%, and 0% in patients with 0, 1 or 2, and 3 risk factors, respectively. There were significant differences in overall survival between the three groups (P < .0001). CONCLUSIONS A preoperative prognostic scoring system using preoperative tumor location, tumor size, and CA19-9 enables preoperative prediction of prognosis and facilitates selection of appropriate treatment for resectable pancreatic cancer.
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Use of Machine-Learning Algorithms in Intensified Preoperative Therapy of Pancreatic Cancer to Predict Individual Risk of Relapse. Cancers (Basel) 2019; 11:cancers11050606. [PMID: 31052270 PMCID: PMC6562932 DOI: 10.3390/cancers11050606] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Although surgical resection is the only potentially curative treatment for pancreatic cancer (PC), long-term outcomes of this treatment remain poor. The aim of this study is to describe the feasibility of a neoadjuvant treatment with induction polychemotherapy (IPCT) followed by chemoradiation (CRT) in resectable PC, and to develop a machine-learning algorithm to predict risk of relapse. Methods: Forty patients with resectable PC treated in our institution with IPCT (based on mFOLFOXIRI, GEMOX or GEMOXEL) followed by CRT (50 Gy and concurrent Capecitabine) were retrospectively analyzed. Additionally, clinical, pathological and analytical data were collected in order to perform a 2-year relapse-risk predictive population model using machine-learning techniques. Results: A R0 resection was achieved in 90% of the patients. After a median follow-up of 33.5 months, median progression-free survival (PFS) was 18 months and median overall survival (OS) was 39 months. The 3 and 5-year actuarial PFS were 43.8% and 32.3%, respectively. The 3 and 5-year actuarial OS were 51.5% and 34.8%, respectively. Forty-percent of grade 3-4 IPCT toxicity, and 29.7% of grade 3 CRT toxicity were reported. Considering the use of granulocyte colony-stimulating factors, the number of resected lymph nodes, the presence of perineural invasion and the surgical margin status, a logistic regression algorithm predicted the individual 2-year relapse-risk with an accuracy of 0.71 (95% confidence interval [CI] 0.56–0.84, p = 0.005). The model-predicted outcome matched 64% of the observed outcomes in an external dataset. Conclusion: An intensified multimodal neoadjuvant approach (IPCT + CRT) in resectable PC is feasible, with an encouraging long-term outcome. Machine-learning algorithms might be a useful tool to predict individual risk of relapse. A small sample size and therapy heterogeneity remain as potential limitations.
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Aoki S, Motoi F, Murakami Y, Sho M, Satoi S, Honda G, Uemura K, Okada KI, Matsumoto I, Nagai M, Yanagimoto H, Kurata M, Fukumoto T, Mizuma M, Yamaue H, Unno M. Decreased serum carbohydrate antigen 19-9 levels after neoadjuvant therapy predict a better prognosis for patients with pancreatic adenocarcinoma: a multicenter case-control study of 240 patients. BMC Cancer 2019; 19:252. [PMID: 30898101 PMCID: PMC6427838 DOI: 10.1186/s12885-019-5460-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/12/2019] [Indexed: 12/15/2022] Open
Abstract
Background Carbohydrate antigen (CA) 19–9 levels after resection are considered to predict prognosis; however, the significance of decreased CA19–9 levels after neoadjuvant therapy has not been clarified. This study aimed to define the prognostic significance of decreased CA19–9 levels after neoadjuvant therapy in patients with pancreatic adenocarcinoma. Methods Between 2001 and 2012, 240 consecutive patients received neoadjuvant therapy and subsequent resection at seven high-volume institutions in Japan. These patients were divided into three groups: Normal group (no elevation [≤37 U/ml] before and after neoadjuvant therapy), Responder group (elevated levels [> 37 U/ml] before neoadjuvant therapy but decreased levels [≤37 U/ml] afterwards), and Non-responder group (elevated levels [> 37 U/ml] after neoadjuvant therapy). Analyses of overall survival and recurrence patterns were performed. Uni- and multivariate analyses were performed to clarify the clinicopathological factors influencing overall survival. The initial metastasis sites were also evaluated in these groups. Results The Responder group received a better prognosis than the Non-responder group (3-year overall survival: 50.6 and 41.6%, respectively, P = 0.026), but the prognosis was comparable to the Normal group (3-year overall survival: 54.2%, P = 0.934). According to the analysis of the receiver operating characteristic curve, the CA19–9 cut-off level defined as no elevation after neoadjuvant therapy was ≤103 U/ml. The multivariate analysis revealed that a CA19–9 level ≤ 103 U/ml, (P = 0.010, hazard ratio: 1.711; 95% confidence interval: 1.133–2.639), tumor size ≤27 mm (P = 0.040, 1.517; (1.018–2.278)), a lack of lymph node metastasis (P = 0.002, 1.905; (1.276–2.875)), and R0 status (P = 0.045, 1.659; 1.012–2.627) were significant predictors of overall survival. Moreover, the Responder group showed a lower risk of hepatic recurrence (18%) compared to the Non-responder group (31%), though no significant difference in loco-regional, peritoneal or other distant recurrence were observed between groups (P = 0.058, P = 0.700 and P = 0.350, respectively). Conclusions Decreased CA19–9 levels after neoadjuvant therapy predicts a better prognosis, with low incidence of hepatic recurrence after surgery. Electronic supplementary material The online version of this article (10.1186/s12885-019-5460-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shuichi Aoki
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Fuyuhiko Motoi
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aobaku, Sendai, Miyagi, 980-8574, Japan.
| | - Yoshiaki Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 734-8553, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, 634-8521, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, 573-1010, Japan
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital, Tokyo, 113-8677, Japan
| | - Kenichiro Uemura
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 734-8553, Japan
| | - Ken-Ichi Okada
- Second Department of Surgery, Wakayama Medical University, Wakayama, 641-8510, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, 577-8502, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, Nara, 634-8521, Japan
| | - Hiroaki Yanagimoto
- Department of Surgery, Kansai Medical University, Osaka, 573-1010, Japan
| | - Masanao Kurata
- Department of Gastointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, 305-8575, Japan
| | - Takumi Fukumoto
- Department of Surgery, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan
| | - Masamichi Mizuma
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, 641-8510, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aobaku, Sendai, Miyagi, 980-8574, Japan
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Piątek M, Kuśnierz K, Bieńkowski M, Pęksa R, Kowalczyk M, Nawrocki S. Primarily resectable pancreatic adenocarcinoma - to operate or to refer the patient to an oncologist? Crit Rev Oncol Hematol 2019; 135:95-102. [PMID: 30819452 DOI: 10.1016/j.critrevonc.2019.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/12/2019] [Accepted: 01/21/2019] [Indexed: 12/13/2022] Open
Abstract
The aim of this work is to investigate the optimal therapeutic sequence of resectable pancreatic cancer - primary surgery with adjuvant therapy or neoadjuvant followed by resection. Application of the neoadjuvant approach in routine treatment of pancreatic cancer is rapidly growing every year, despite the lack of final results from randomized trials. Recent advancements in the adjuvant therapy, due to the more effective chemotherapy regimens, favor the upfront surgery strategy. On the other hand, theoretical background and metaanalyses favor the neoadjuvant strategy. Currently, primary resection with adjuvant chemotherapy remains the standard approach in resectable pancreatic cancer, but the first recommendations considering the neoadjuvant approach as an option seem to arise among the scientific societies with a global impact. Preliminary results of Prodige 24 study and PREOPANC-1 trial demonstrates that both options are worth further evaluation in clinical trials. Their results should soon provide more answers to this important clinical questions.
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Affiliation(s)
- Michał Piątek
- Department of Oncology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Kuśnierz
- Department of Gastrointestinal Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Rafał Pęksa
- Department of Patomorphology, Medical University of Gdańsk, Poland
| | - Marek Kowalczyk
- Department of Radiotherapy, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Sergiusz Nawrocki
- Department of Radiotherapy, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
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Bradley A, Van Der Meer R. Neoadjuvant therapy versus upfront surgery for potentially resectable pancreatic cancer: A Markov decision analysis. PLoS One 2019; 14:e0212805. [PMID: 30817807 PMCID: PMC6394923 DOI: 10.1371/journal.pone.0212805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/09/2019] [Indexed: 12/16/2022] Open
Abstract
Background Neoadjuvant therapy has emerged as an alternative treatment strategy for potentially resectable pancreatic cancer. In the absence of large randomized controlled trials offering a direct comparison, this study aims to use Markov decision analysis to compare efficacy of traditional surgery first (SF) and neoadjuvant treatment (NAT) pathways for potentially resectable pancreatic cancer. Methods An advanced Markov decision analysis model was constructed to compare SF and NAT pathways for potentially resectable pancreatic cancer. Transition probabilities were calculated from randomized control and Phase II/III trials after comprehensive literature search. Utility outcomes were measured in overall and quality-adjusted life months (QALMs) on an intention-to-treat basis as the primary outcome. Markov cohort analysis of treatment received was the secondary outcome. Model uncertainties were tested with one and two-way deterministic and probabilistic Monte Carlo sensitivity analysis. Results SF gave 23.72 months (18.51 QALMs) versus 20.22 months (16.26 QALMs). Markov Cohort Analysis showed that where all treatment modalities were received NAT gave 35.05 months (29.87 QALMs) versus 30.96 months (24.86QALMs) for R0 resection and 34.08 months (29.87 QALMs) versus 25.85 months (20.72 QALMs) for R1 resection. One-way deterministic sensitivity analysis showed that NAT was superior if the resection rate was greater than 51.04% or below 75.68% in SF pathway. Two-way sensitivity analysis showed that pathway superiority depended on obtaining multimodal treatment in either pathway. Conclusion Whilst NAT is a viable alternative to traditional SF approach, superior pathway selection depends on the individual patient’s likelihood of receiving multimodal treatment in either pathway.
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Affiliation(s)
- Alison Bradley
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, United Kingdom
- West of Scotland Pancreatic Cancer Unit, Glasgow Royal Infirmary, Glasgow, Scotland, United Kingdom
- * E-mail:
| | - Robert Van Der Meer
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, Scotland, United Kingdom
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46
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Chemotherapy Versus Chemoradiation as Preoperative Therapy for Resectable Pancreatic Ductal Adenocarcinoma: A Propensity Score Adjusted Analysis. Pancreas 2019; 48:216-222. [PMID: 30629022 DOI: 10.1097/mpa.0000000000001231] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although the use of neoadjuvant therapy for resectable pancreatic ductal adenocarcinoma is increasing, the optimal preoperative treatment regimen remains poorly defined. METHODS All patients with resectable pancreatic ductal adenocarcinoma who received preoperative chemotherapy alone (12%) or chemoradiation therapy (CRT) alone (88%) before pancreatectomy between 1999 and 2014 were included. Propensity score matching with inverse probability weighting was conducted based on age, baseline carbohydrate antigen 19-9, and procedure type. RESULTS Patients who received preoperative CRT were more likely to undergo a margin negative (91% vs 79%, P < 0.01) and node negative (53% vs 23%, P < 0.01) resection and experience less locoregional recurrence (LR; 16% vs 33%, P < 0.01) but similar median overall survival (OS; 33.6 vs 26.4 months, P = 0.09). On multivariate analysis, carbohydrate antigen 19-9 (hazard ratio, 1.2; 95% confidence interval [CI], 1.1-1.3) and positive lymph nodes (hazard ratio, 1.5; 95% CI, 1.0-2.2) were associated with OS, whereas tumor size (odds ratio [OR], 1.5; 95% CI, 1.3-1.8), positive lymph nodes (OR, 3.1; 95% CI, 1.8-5.6), and preoperative chemotherapy (OR, 1.8; 95% CI, 1.1-2.9) were associated with LR. CONCLUSIONS Preoperative CRT is associated with less margin and lymph node positivity, reduced LR, and similar OS compared with preoperative chemotherapy.
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Raufi AG, Manji GA, Chabot JA, Bates SE. Neoadjuvant Treatment for Pancreatic Cancer. Semin Oncol 2019; 46:19-27. [DOI: 10.1053/j.seminoncol.2018.12.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 02/06/2023]
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48
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Ren X, Wei X, Ding Y, Qi F, Zhang Y, Hu X, Qin C, Li X. Comparison of neoadjuvant therapy and upfront surgery in resectable pancreatic cancer: a meta-analysis and systematic review. Onco Targets Ther 2019; 12:733-744. [PMID: 30774360 PMCID: PMC6348975 DOI: 10.2147/ott.s190810] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective The role of neoadjuvant therapy (NAT) in resectable pancreatic cancer (RPC) remains controversial. Therefore, this meta-analysis was performed to compare the clinical differences between NAT and upfront surgery in RPC. Materials and methods A systematic literature search was performed in PubMed, Embase, Web of Science, and the Cochrane Register of Controlled Trials databases. Only patients with RPC who underwent tumor resection and received adjuvant or neoadjuvant treatment were enrolled. The OR or HR and 95% CIs were calculated employing fixed-effects or random-effects models. The HR and its 95% CI were extracted from each article that provided survival curve. Publication bias was estimated using funnel plots and Egger’s regression test. Results In total, eleven studies were included with 9,386 patients. Of these patients, 2,508 (26.7%) received NAT. For patients with RPC, NAT resulted in an increased R0 resection rate (OR=1.89; 95% CI=1.26–2.83) and a reduced positive lymph node rate (OR=0.34; 95% CI=0.31–0.37) compared with upfront surgery. Nevertheless, patients receiving NAT did not exhibit a significantly increased overall survival (OS) time (HR=0.91; 95% CI=0.79–1.05). Conclusion In patients with RPC, R0 resection rate and positive lymph node rate after NAT were superior to those of patients with upfront surgery. The NAT group exhibited no significant effect on OS time when compared with the upfront surgery group. However, this conclusion requires more clinical evidence to improve its credibility.
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Affiliation(s)
- Xiaohan Ren
- Department of First Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210009, China
| | - Xiyi Wei
- Department of First Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210009, China
| | - Yichao Ding
- Department of First Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210009, China
| | - Feng Qi
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210009, China,
| | - Yundi Zhang
- Department of First Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210009, China
| | - Xin Hu
- Department of First Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210009, China
| | - Chao Qin
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210009, China,
| | - Xiao Li
- Department of Urology, Jiangsu Institute of Cancer Research, Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, Jiangsu 210009, China,
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Nelson DW, Chang SC, Grunkemeier G, Dehal AN, Lee DY, Fischer TD, DiFronzo LA, O’Connor VV. Resectable Distal Pancreas Cancer: Time to Reconsider the Role of Upfront Surgery. Ann Surg Oncol 2018; 25:4012-4019. [DOI: 10.1245/s10434-018-6765-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Indexed: 12/23/2022]
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50
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Fisher AV, Abbott DE, Venkatesh M, Leverson GE, Campbell-Flohr SA, Ronnekleiv-Kelly SM, Greenberg CC, Winslow ER, Weber SM. The Impact of Hospital Neoadjuvant Therapy Utilization on Survival Outcomes for Pancreatic Cancer. Ann Surg Oncol 2018; 25:2661-2668. [DOI: 10.1245/s10434-018-6650-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Indexed: 08/30/2023]
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