The Landmark Series: Preoperative Therapy for Pancreatic Cancer

Neoadjuvant treatment of pancreatic ductal adenocarcinoma: Whom, when and how

Pancreatic ductal adenocarcinoma (PDAC), which is notorious for its aggressiveness and poor prognosis, remains an area of great unmet medical need, with a 5-year survival rate of 10% - the lowest of all solid tumours. At diagnosis, only 20% of patients have resectable pancreatic cancer (RPC) or borderline RPC (BRPC) disease, while 80% of patients have unresectable tumours that are locally advanced pancreatic cancer (LAPC) or have distant metastases. Nearly 60% of patients who undergo upfront surgery for RPC are unable to receive adequate adjuvant chemotherapy (CHT) because of postoperative complications and early cancer recurrence. An important paradigm shift to achieve better outcomes has been the sequence of therapy, with neoadjuvant CHT preceding surgery. Three surgical stages have emerged for the preoperative assessment of nonmetastatic pancreatic cancers: RPC, BRPC, and LAPC. The main goal of neoadjuvant treatment (NAT) is to improve postoperative outcomes through enhanced selection of candidates for curative-intent surgery by identifying patients with aggressive or metastatic disease during initial CHT, reducing tumour volume before surgery to improve the rate of margin-negative resection (R0 resection, a microscopic margin-negative resection), reducing the rate of positive lymph node occurrence at surgery, providing early treatment of occult micrometastatic disease, and assessing tumour chemosensitivity and tolerance to treatment as potential surgical criteria. In this editorial, we summarize evidence concerning NAT of PDAC, providing insights into future practice and study design. Future research is needed to establish predictive biomarkers, measures of therapeutic response, and multidisciplinary strategies to improve patient-centered outcomes.

Evidence and Future Perspectives for Neoadjuvant Therapy for Resectable and Borderline Resectable Pancreatic Cancer: A Scoping Review

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.

ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer

Pancreatic adenocarcinoma is an aggressive disease marked by high rates of both local and distant failure. In the minority of patients with potentially resectable disease, multimodal treatment paradigms have allowed for prolonged survival in an increasingly larger pool of well-selected patients. Therefore, it is critical for surgical oncologists to be abreast of current guideline recommendations for both surgical management and multimodal therapy for pancreas cancer. We discuss these guidelines, as well as the underlying data supporting these positions, to offer surgical oncologists a framework for managing patients with pancreatic adenocarcinoma.

Comparison Between Plastic and Metallic Biliary Stent Placement for Preoperative Patients with Pancreatic Head Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Optimal preoperative biliary drainage for patients with pancreatic cancer before pancreatoduodenectomy remains unclear. This study aimed to investigate the comparison of efficacy and safety between a metallic stent (MS) and a plastic stent (PS).

METHODS

Comparative studies on the use of MS and PS for pancreatic cancer before pancreatoduodenectomy were systematically searched using the MEDLINE and Web of Science databases. Pre- and postoperative data also were extracted. Random-effects meta-analyses were performed to compare post-endoscopic retrograde cholangiopancreatography (ERCP) complications as well as intra- and postoperative outcomes between the two arms of the study, and pooled odds ratios (ORs) or mean differences (MDs) were calculated with 95 percent confidence intervals (CIs).

RESULTS

The study analyzed 12 studies involving 683 patients. Insertion of MS was associated with a lower incidence of re-intervention (OR, 0.06; 95% CI 0.03-0.15; P < 0.001), increased post-ERCP adverse events (OR, 2.22; 95% CI 1.13-4.36; P = 0.02), and similar operation time (MD, 18.0 min; 95% CI -29.1 to 65.6 min; P = 0.46), amount of blood loss (MD, 43.0 ml; 95% CI -207.1 to 288.2 ml; P = 0.73), and surgical complication rate (OR, 0.78; 95% CI 0.53-1.15; P = 0.21). The cumulative stent patency rate after 3 months was higher in the MS group than in the PS group (70-100 % vs 30.0-45.0 %).

CONCLUSION

For biliary drainage in patients with pancreatic cancer during this era of multidisciplinary treatment, MS use might be the first choice because MS provides a more durable biliary drainage and a similar risk of postoperative outcomes compared with PS.

Risk factors for early recurrence in patients with pancreatic ductal adenocarcinoma who underwent curative resection

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers, and surgical resection is the only potentially curative approach. However, the rate of recurrence remains high, particularly within the first 6 months, and is associated with a poor prognosis. The present study evaluated the clinical characteristics and risk factors for early recurrence in pancreatic ductal adenocarcinoma (PDAC) patients who underwent curative resection, regardless of the use of neoadjuvant chemotherapy, to identify predictive factors associated with early recurrence and poor outcomes as well as to determine the optimal treatment strategy for patients at high risk of early recurrence after surgical resection.

METHODS

Patients who underwent pancreatic resection for PDAC at our institution from 2013 to 2021 were included in this study. We investigated the clinicopathological features of patients in groups: those with recurrence within 6 months, recurrence between 6 and 12 months, and recurrence beyond 12 months or no recurrence. A logistic regression analysis identified covariates associated with early recurrence at 6 and 12 months.

RESULTS

The study included 403 patients with a median follow-up of 25.7 months. Recurrence was observed in 279 patients, with 14.6% recurring within 6 months, 23.3% within 6-12 months, and 62% after 12 months or not at all. The preoperative CA19-9 level, modified Glasgow prognostic score (mGPS), and positive peritoneal cytology were significant risk factors for early recurrence within 6 months, while positive peritoneal cytology, lymph node metastasis, and the absence of adjuvant chemotherapy were significant risk factors for recurrence within 12 months. For patients who received preoperative chemotherapy or chemoradiotherapy, the preoperative CA19-9 level, mGPS, and positive peritoneal cytology were significant independent risk factors for early recurrence within 6 months, while positive peritoneal cytology, lymph node metastasis, and the absence of adjuvant chemotherapy were significant independent risk factors for recurrence within 12 months. The study concluded that the overall survival after surgical resection for potentially resectable PDAC worsened according to the number of risk factors present in the patient.

CONCLUSIONS

We clarified that preoperative CA19-9, positive peritoneal cytology, and the lack of adjuvant chemotherapy were consistent predictors for early recurrence within 6 and 12 months. In addition, an increased number of risk factors affecting the patient was associated with a poorer overall survival after potentially curable resection. Calculating the number of risk factors for early recurrence may be an essential predictive factor when considering treatment strategies.

Delays to surgery following chemoradiotherapy lead to poorer oncologic outcomes in patients with localized pancreatic adenocarcinoma

BACKGROUND

although neoadjuvant chemoradiotherapy (NCRT) and surgery are accepted as treatments for pancreatic ductal adenocarcinoma (PDAC), some authors have highlighted the risks of delaying surgery. The objective of this study was to analyze the impact of prolonging the time interval between NCRT and surgery (NCRT-TTS) in PDAC.

METHODS

patients treated with NCRT and pancreatoduodenectomy (PD) were identified. Clinical, histopathological variables were analyzed about whether NCRT-TTS was greater or less than 50 days. Five- and ten-year overall survival (OS) and disease-free survival (DFS) were analyzed depending on whether the delay was greater than 50 days or not.

RESULTS

one hundred (8.3 %) of 120 eligible patients underwent PD (61 male, median age of 63.7 years). In 71 (71 %) patients, the median NCRT-TTS was 39 (24-50) days and in 29 (29 %) 61 days. There were no differences between the two groups except for carbohydrate antigen 19-9 (CA 19-9) levels, the incidence of cholangitis, American Society of Anesthesiologists (ASA) score, intraoperative blood transfusions and degree of histopathologic response (all p < 0.001). Median DFS when the NCRT-TTS was less than 50 days was higher than when the interval exceeded 50 days (51.0 months [95 % CI: 20.3-81.6] vs 17.0 months [95 %: CI 10.9-23.0]; HR [95 % CI 1.08-3.46], p = 0.026). Five-year DFS was higher in the subgroup with NCRT-TTS of less than 50 days compared to the group with an interval of more than 50 days (43.5 % vs 23.65 % [HR 1.812, 95 % CI: 1.001-3.280], p = 0.050).

CONCLUSIONS

an increase in the NCRT-TTS > 50 days is associated with poorer OS and DFS in patients with localized PDAC treated with NCRT and PD.

Intraoperative Radiation Therapy for Gastrointestinal Malignancies

Despite improvements in definitive therapy, many patients with gastrointestinal malignancies experience local recurrences or have unresectable disease making subsequent management often challenging and morbid. Although higher doses of radiation may offer improved local control, the ability for dose escalation of external beam radiation therapy is often limited by adjacent radiosensitive structures. Intraoperative radiation therapy allows for additional radiotherapy to be delivered directly to the tumor or areas at highest risk for local recurrence while minimizing toxicity to adjacent structures, offering potentially improved outcomes for patients with unresectable disease or those with a high risk of local recurrence.

The Current Role of Radiation in Pancreatic Cancer and Future Directions

Survival outcomes for localized pancreatic adenocarcinoma remains poor. Multimodality therapeutic regimens are critical to maximizing survival outcomes for these patients, which includes the use of systemic therapy, surgery, and radiation. In this review, the evolution of radiation techniques are discussed with a focus on modern techniques such as intensity modulated radiation and stereotactic body radiation therapy. However, the current role of radiation within the most common clinical scenarios for pancreatic cancer in the neoadjuvant, definitive, and adjuvant settings continues to be highly debated. The role of radiation in these settings is reviewed in the context of historical and modern clinical studies. In addition, emerging concepts including dose-escalated radiation, magnetic resonance-guided radiation therapy, and particle therapy are discussed to promote an understanding of how such concepts may change the role of radiation in the future.

Advances in the Surgical Treatment of Pancreatic Cancer

Three recent advances in the surgical approach to pancreatic cancer over the past decade have improved both short- and long-term outcomes for patients with nonmetastatic, operable pancreatic cancer. These include (1) minimally invasive pancreatectomy to reduce operative morbidity while adhering to principles of open oncologic resections, (2) neoadjuvant chemotherapy to treat radiographically occult metastatic disease and improve locoregional control, and (3) applying irreversible electroporation as an adjunct to surgery, allowing a fraction of locally advanced pancreatic cancer to be resected.

Neoadjuvant chemotherapy or upfront surgery in localized pancreatic cancer: a contemporary analysis

Neoadjuvant chemotherapy is considered a new treatment option for potentially resectable pancreatic cancer. However, data are not well established on overall survival and delaying surgery in resectable pancreatic cancer, as well as on those patients that ultimately cannot undergo surgery. We analyzed pancreatic cancer patients treated in a tertiary hospital from January 2016 to December 2020. Patients with resectable stage I and II pancreatic cancer were evaluated regarding surgery, neoadjuvant treatment, and other clinical demographics. The survival function was estimated using the Kaplan–Meier method, and the relationship between the variables of interest and the overall survival (OS) was assessed by adopting the proportional regression Cox models. A total of 216 patients were evaluated. 81 of them with resectable/borderline resectable disease and 135 with unresectable /metastatic disease at diagnosis. Median OS for stage I and II disease were 36 and 28 months, respectively. For resectable pancreatic cancer median OS was 28 months, for borderline resectable pancreatic cancer median OS was 11 months. Median OS for stage III (locally advanced) and stage IV (metastatic) were 10 and 7 months, respectively (p < 0.0001). Median OS of 9 months were obtained for patients with stage I and II that did not undergo surgery compared to 25 months in patients that underwent surgery in any time (p < 0.001). Comparing patients with localized disease, median OS for patients treated with upfront surgery was 28 months, compared to 15 months in patients treated with neoadjuvant approach (p = 0.04). Most patients that did not undergo surgery have decline of performance status or disease progression on neoadjuvant treatment. On multivariable analysis in pancreatic cancer stages I and II, including age, sex, borderline or resectable disease, CA 19–9, positive lymph nodes and neoadjuvant treatment, the surgery was the only factor associated with improved overall survival (p = 0.04). Upfront surgery should still be considered a standard of care approach for resectable pancreatic cancer. Biomarker driven studies and randomized trials with combination therapies are necessary to address neoadjuvant chemotherapy and delaying surgery in purely resectable pancreatic cancer.

Trends in Preoperative Chemotherapy Utilization for Proximal Pancreatic Cancer: Are We Making Progress?

BACKGROUND

While it has been shown that neoadjuvant chemotherapy (NCT) for pancreatic cancer (PDAC) undergoing pancreaticoduodenectomy (PD) is critical for optimal oncologic management, NCT is (A) not universally practiced and (B) the reasons ill-defined. This study investigates national rates, trends, and factors affecting NCT utilization.

PATIENTS AND METHODS

Using the National Cancer Database, patients who underwent PD for PDAC between 2006 and 2017 were identified. Changes in chemotherapy sequence over time were identified. For patients diagnosed after 2010, multivariable logistic regression models for factors affecting NCT were created.

RESULTS

A total of 128,980 patients were diagnosed and 23,206 underwent surgery. Three thousand five (12.9%) received NCT with a preoperative chemotherapy (NCT + PCT) utilization rate of 7.3% in 2004 that increased to 36.8% in 2017. Factors affecting utilization of preoperative chemotherapy were age (OR 0.972), academic and integrated network institutions (OR 1.916, OR 1.559), institutional case volume (OR 1.007), distance from the hospital (OR 1.002), stage (IB OR 3.108, IIA OR 3.133, IIB OR 3.775, III OR 3.782), grade IV (OR 1.977), and insurance status (private OR 2.371, Medicaid OR 1.811, and Medicare OR 2.191, government OR 2.645).

CONCLUSION

Even though more than 3/5 of patients receive no preoperative chemotherapy (NCT + PCT) and nearly 1/5 of patients still receive no chemotherapy at all, utilization of NCT is increasing. Moreover, since this study demonstrates that omission of NCT is associated with modifiable factors such as type of institution and health care disparity, mechanisms (reimbursement, policy) geared to change current national practice patterns may most immediately affect optimal oncologic management.

Alterations in Somatic Driver Genes Are Associated with Response to Neoadjuvant FOLFIRINOX in Patients with Localized Pancreatic Ductal Adenocarcinoma

BACKGROUND

There is increased use of neoadjuvant fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) in the management of localized pancreatic ductal adenocarcinoma (PDAC), yet there are few validated biomarkers of treatment response.

STUDY DESIGN

Consecutive patients (n = 196) with resectable, borderline resectable or locally advanced PDAC (2012-2019) receiving FOLFIRINOX as initial treatment and with targeted sequencing of a pretreatment biopsy were identified in a prospective institutional database. Genomic alterations were determined in the 4 driver mutations (KRAS, TP53, CDKN2A, SMAD4), and associations between genomic alterations and clinical outcomes were assessed.

RESULTS

Alterations in KRAS (n = 172, 87.8%) and TP53 (n = 131, 66.8%) were common; alterations in CDKN2A (n = 49, 25.0%) and SMAD4 (n = 36, 18.4%) were less frequently observed. A total of 105 patients (53.6%) were able to undergo resection, of whom 8 (7.6%) had a complete/near-complete pathologic response. There were no somatic alterations associated with major pathologic response. Alterations in SMAD4 were associated with a lower rate of surgical resection (27.8% vs 59.4%, p < 0.001); this was additionally observed in a multivariable regression model accounting for resectability status (OR 0.35, 95% confidence interval [CI] 0.15-0.85). Thirty-three patients (16.8%) developed metastatic disease while on neoadjuvant therapy. SMAD4 alterations were associated with a significant risk of metastatic progression on therapy when controlling for resectability status (OR 3.31, 95% CI 1.44-7.60).

CONCLUSIONS

SMAD4 alterations are associated with more frequent development of metastasis during neoadjuvant FOLFIRINOX and lower probability of reaching surgical resection. Evaluation of alternative chemotherapy regimens in patients with SMAD4 alterations will be important to distinguish whether this represents a prognostic or predictive biomarker.

Radiation therapy in borderline resectable pancreatic cancer: A review

BACKGROUND

Borderline resectable pancreatic cancer constitutes a complex clinical entity, presenting the clinician with a locally aggressive disease that has a proclivity for distant spread. The benefits of radiation therapy, such as improved local control and improved survival, have been questioned. In this review we seek to summarize the existing evidence on radiation therapy in borderline resectable pancreatic cancer and highlight future areas of research.

METHODS

A comprehensive review of PubMed for clinical studies reporting outcomes in borderline resectable pancreatic cancer was performed in June 2021, with an emphasis placed on prospective studies.

RESULTS

Radiologic "downstaging" in borderline resectable pancreatic cancer is a rare event, although some evidence shows increased clinical response to neoadjuvant chemotherapy over radiation therapy. Margin status seems to be equivalent between regimens that use neoadjuvant chemotherapy alone and regimens that include neoadjuvant radiation therapy. Local control in borderline resectable pancreatic cancer is likely improved with radiation therapy; however, the benefit of improved local control in a disease marked by systemic failure has been questioned. Although some studies have shown improved survival with radiation therapy, differences in the delivery and tolerance of chemotherapy between the neoadjuvant and adjuvant setting confound these results. When the evidence is evaluated as a whole, there is no clear survival benefit of radiation therapy in borderline resectable pancreatic cancer.

CONCLUSION

Once considered a staple of therapy, the role of radiation therapy in borderline resectable pancreatic cancer is evolving as systemic therapy regimens continues to improve. Increased clinical understanding of disease phenotype and response are needed to accurately tailor therapy for individual patients and to improve outcomes in this complex patient population.