Chemotherapy in elderly patients with pancreatic cancer: Efficacy, feasibility and future perspectives

Update on the management of older patients with pancreatic adenocarcinoma: a perspective from medical oncology

In the context of pancreatic cancer, surgical intervention is typically recommended for localized tumours, whereas chemotherapy is the preferred approach in the advanced and/or metastatic setting. However, pancreatic cancer is closely linked to ageing, with an average diagnosis at 72 years. Paradoxically, despite its increased occurrence among older individuals, this population is often underrepresented in clinical studies, complicating the decision-making process. Age alone should not determine the therapeutic strategy but, given the high comorbidity and mortality of this disease, a comprehensive geriatric assessment (CGA) is necessary to define the best treatment, prevent toxicity, and optimize older patient care. In this review, a group of experts from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica, SEOM), the Spanish Cooperative Group for the Treatment of Digestive Tumours (Grupo Español de Tratamiento de los Tumores Digestivos, TTD), and the Multidisciplinary Spanish Group of Digestive Cancer (Grupo Español Multidisciplinar en Cáncer Digestivo, GEMCAD) have assessed the available scientific evidence and propose a series of recommendations on the management and treatment of the older population with pancreatic cancer.

Plumbagin binds to epidermal growth factor receptor and mitigate the effects of epidermal growth factor micro-environment in PANC-1 cells

A sustained increase in the mortality of pancreatic cancer (PC) and sudden metastasis-related mortality is a cause for concern. Aberrant expression of epidermal growth factor (EGF) receptor (EGFR) is noted in several cases of PC metastasis. The present study is aimed at analyzing the expression of EGFR in PC and its relevance to the progression of PC. Despite the number of studies that have shown the benefits of plumbagin on PC cells, its role on cancer stem cells remains largely unknown. To this end, the study used an EGF micro-environment to make cancer stem cells in vitro and ascertained the role of plumbagin in mitigating the actions of EGF. The kaplan-meier (KM) plot indicated reduced overall survival (OS) analysis in PC patients with high EGFR than low EGFR expression. Plumbagin pre-treatment significantly prevented EGF-induced survival, epithelial-to-mesenchymal transition (EMT), clonogenesis, migration, matrix metalloproteinase -2 (MMP-2) gene expression and its secretion, and matrix protein hyaluron production in PANC-1 cells. The computational studies indicate the greater affinity of plumbagin with different domains of EGFR than gefitinib. Several hallmarks of resistance and migration due to EGF are effectively attenuated by plumbagin. Collectively, these results warrant investigating the actions of plumbagin in a pre-clinical study to substantiate these findings.

Efficacy and Safety of Chemotherapy in Elderly Patients with Unresectable Pancreatic Cancer

BACKGROUND/AIMS

The incidence of pancreatic cancer (PC) is gradually increasing among elderly individuals, but there are insufficient clinical data on elderly individuals. To determine the efficacy and safety of chemotherapy, we compared the. the outcomes of elderly patients with unresectable PC.

METHODS

We enrolled patients aged 75 years or older diagnosed with PC from 1 January 2010 to 30 November 2021. Propensity score matching (PSM) was used to reduce the heterogeneity of the study population. For efficacy evaluation, the median overall survival (OS) was estimated for the chemotherapy and nonchemotherapy groups. Chemotherapy tolerability evaluations were also investigated.

RESULTS

The study included 115 patients, 47 of whom received chemotherapy and 68 who did not. After PSM, compared with the nonchemotherapy group, the chemotherapy group had more myocardial infarctions (14.6 vs. 0.0%, p < 0.001) and chronic obstructive pulmonary disease (4.4 vs. 0.0%, p = 0.043). The primary endpoint, median OS, was significantly different in the with vs. without chemotherapy groups (203 vs. 106 days, p = 0.013). In the chemotherapy group, 10 patients (21.3%) discontinued treatment due to adverse events. However, there were no reports of death due to severe adverse events.

CONCLUSIONS

This study demonstrated that chemotherapy improved median OS among elderly patients. These data could support the use of chemotherapy for elderly patients with unresectable PC.

Predictive model of chemotherapy-related toxicity in elderly Chinese cancer patients

Purpose: Older cancer patients are more likely to develop and die from chemotherapy-related toxicity. However, evidence on drug safety and optimal effective doses is relatively limited in this group. The aim of this study was to develop a tool to identify elderly patients vulnerable to chemotherapy toxicity. Patients and methods: Elderly cancer patients ≥60 years old who visited the oncology department of Peking Union Medical College Hospital between 2008 and 2012 were included. Each round of chemotherapy was regarded as a separate case. Clinical factors included age, gender, physical status, chemotherapy regimen and laboratory tests results were recorded. Severe (grade ≥3) chemotherapy-related toxicity of each case was captured according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0. Univariate analysis was performed by chi-square statistics to determine which factors were significantly associated with severe chemotherapy toxicity. Logistic regression was used to build the predictive model. The prediction model was validated by calculating the area under the curve of receiver operating characteristic (ROC). Results: A total of 253 patients and 1,770 cases were included. The average age of the patients was 68.9 years. The incidence of grade 3-5 adverse events was 24.17%. Cancer type (non-GI cancers), BMI<20 kg/m2, KPS<90%, severe comorbidity, polychemotherapy, standard dose chemotherapy, low white blood cells count, anemia, low platelet cells count, low creatine level and hypoalbuminemia were associated with severe chemotherapy-related toxicity. We used these factors to construct a chemotherapy toxicity prediction model and the area under the ROC curve was 0.723 (95% CI, 0.687-0.759). Risk of toxicity increased with higher risk score (11.98% low, 31.51% medium, 70.83% high risk; p < 0.001). Conclusion: We constructed a predictive model of chemotherapy toxicity in elderly cancer patients based on a Chinese population. The model can be used to guide clinicians to identify vulnerable population and adjust treatment regimens accordingly.

Systematic Review of Single-Agent vs. Multi-Agent Chemotherapy for Advanced Pancreatic Adenocarcinoma in Elderly vs. Younger Patients

PURPOSE

To systematically review all studies comparing multi-agent to single-agent chemotherapy in the first and second-line setting for unresectable pancreatic adenocarcinoma, so as to compare the outcomes of young and elderly patients.

METHODS

This review searched three databases for relevant studies. The inclusion criteria were diagnosis of locally advanced or metastatic pancreatic adenocarcinoma, comparison of an elderly versus young population, comparison of single-agent versus multi-agent chemotherapy, data on survival outcomes, and randomised controlled trials. The exclusion criteria were phase I trials, incomplete studies, retrospective analyses, systematic reviews, and case reports. A meta-analysis was performed on second-line chemotherapy in elderly patients.

RESULTS

Six articles were included in this systematic review. Three of these studies explored first-line treatment and three explored second-line treatment. In the subgroup analysis, the meta-analysis showed statistically improved overall survival for elderly patients receiving single-agent second-line treatment.

CONCLUSIONS

This systematic review confirmed that combination chemotherapy improved survival in the first-line treatment of advanced pancreatic adenocarcinoma, regardless of age. The benefit of combination chemotherapy in second-line studies for elderly patients with advanced pancreas cancer was less clear.

Analysis of Risk Factors for Distant Metastasis of Pancreatic Ductal Adenocarcinoma without Regional Lymph Node Metastasis and a Nomogram Prediction Model for Survival

Background

Negative regional lymph nodes do not indicate a lack of distant metastasis. A considerable number of patients with negative regional lymph node pancreatic cancer will skip the step of regional lymph node metastasis and directly develop distant metastasis.

Methods

We retrospectively analyzed the clinicopathological characteristics of patients with negative regional lymph node pancreatic cancer and distant metastasis in the Surveillance, Epidemiology, and End Results database from 2010 to 2015. Multivariate logistic analysis and Cox analysis were used to determine the independent risk factors that promoted distant metastasis and the 1-, 2-, and 3-year cancer-specific survival in this subgroup.

Results

Sex, age, pathological grade, surgery, radiotherapy, race, tumor location, and tumor size were significantly correlated with distant metastasis (P < 0.05). Among these factors, pathological grade II and above, tumor site other than the pancreatic head, and tumor size >40 mm were independent risk factors for distant metastasis; age ≥60 years, tumor size ≤21 mm, surgery, and radiation were protective factors against distant metastasis. Age, pathological grade, surgery, chemotherapy, and metastasis site were identified as predictors of survival. Among them, age ≥40 years, pathological grade II and above, and multiple distant metastasis were considered independent risk factors for cancer-specific survival. Surgery and chemotherapy were considered protective factors for cancer-specific survival. The prediction performance of the nomogram was significantly better than that of the traditional American Joint Committee on Cancer tumor, node, metastasis staging system. We also established an online dynamic nomogram calculator, which can predict the survival rate of patients at different follow-up time points.

Conclusion

Pathological grade, tumor location, and tumor size were independent risk factors for distant metastasis in pancreatic ductal adenocarcinoma with negative regional lymph nodes. Older age, smaller tumor size, surgery, and radiotherapy were protective factors against distant metastasis. A new nomogram that was constructed could effectively predict cancer-specific survival in pancreatic ductal adenocarcinoma with negative regional lymph nodes and distant metastasis. Furthermore, an online dynamic nomogram calculator was established.

Elderly Pancreatic Adenocarcinoma Cancer Patients Could Benefit From Postoperative Chemotherapy

OBJECTIVES

The study aim to investigate whether elderly patients with resectable pancreatic ductal adenocarcinoma (PDAC) could benefit from postoperative chemotherapy.

METHODS

This study selects the data of PDAC patients who were diagnosed between 2004 and 2014 from the Surveillance, Epidemiology, and End Results program. Median overall survival (mOS) is determined by Kaplan-Meier survival curves. Multivariate logistic regression analysis and hazard ratio are employed to assess the association among potential prognostic factors. Propensity score matching evaluation is used to reduce bias.

RESULTS

In total, there are 11,865 PDAC patients selected from the Surveillance, Epidemiology, and End Results database. Elderly PDAC patients have poor prognoses compared with younger (mOS, 15 vs 21 months). The possible reason might be that the elderly patients are less likely to receive postoperative chemotherapy. After propensity score matching, it is found that, for those who receive postoperative chemotherapy, although the mOS of older group is not as good as that of the younger group (mOS, 20 vs 23 months; 18-month survival rate: 53.4% vs 61.3%), the mOS of older group prolonged by postoperative chemotherapy is similar to that of younger group (9 vs 9 months).

CONCLUSIONS

Elderly PDAC patients (≥70 years) might benefit from the currently used postoperative chemotherapy regimens.

Low preoperative skeletal muscle index increases the risk of mortality among resectable pancreatic cancer patients: A retrospective study

BACKGROUND

The only potential curative treatment for patients with pancreatic cancer is surgery; however, the prognosis remains poor. Measures of body composition based on computed tomography (CT) have been established as a reliable predictor of the prognosis of cancer patients after surgery.

AIM

To elucidate the associations of body composition measures derived from preoperative CT scans with the prognosis of patients with pancreatic cancer.

METHODS

One hundred fifteen patients undergoing pancreatic resection with curative intent for pancreatic cancer were retrospectively enrolled. A preoperative CT scan at the third lumbar vertebral level was performed to measure the skeletal muscle index (SMI), mean skeletal muscle radiodensity, subcutaneous adipose tissue index, and visceral to subcutaneous adipose tissue area ratio. The clinical and pathological data were collected. The effects of these factors on long-term survival were evaluated.

RESULTS

Among the five body composition measures, only low SMI independently predicted overall survival (OS) [hazard ratio (HR): 2.307; 95% confidence interval (CI): 1.210-4.402] and recurrence-free survival (HR: 1.907; 95%CI: 1.147-3.171). Furthermore, patients with low SMI (vs high SMI) were older (68.8 ± 9.3 years vs 63.3 ± 8.4 years); low SMI was present in 27 of 56 patients (48.2%) aged 65 years and older and in 11 of 59 younger patients (18.6%). In addition, subgroup analyses revealed that the correlation between low SMI and OS was observed only in patients aged 65 years and older.

CONCLUSION

Low preoperative SMI was more prevalent in elderly patients and was associated with a poor prognosis among pancreatic cancer patients, especially elderly patients.

Initial treatment is associated with improved survival and end-of-life outcomes for patients with pancreatic cancer: a cohort study

Background

We describe the association between initial treatment and end-of-life (EOL) outcomes among patients with pancreatic ductal adenocarcinoma (PDAC).

Methods

This population-based cohort study included patients with PDAC who died from April 2010–December 2017 in Ontario, Canada using administrative databases. We used multivariable models to explore the association between index cancer treatment (no cancer-directed therapy, radiation, chemotherapy, surgery alone, and surgery and chemotherapy), and primary (mortality, healthcare encounters and palliative care) and secondary outcomes (location of death, hospitalizations, and receipt of chemotherapy within the last 30 days of life).

Results

In our cohort (N = 9950), 56% received no cancer-directed therapy, 5% underwent radiation, 27% underwent chemotherapy, 7% underwent surgery alone, and 6% underwent surgery and chemotherapy. Compared to no cancer-directed therapy, radiation therapy (HR = 0.63), chemotherapy (HR = 0.43) surgery alone (HR = 0.32), and surgery and chemotherapy (HR = 0.23) were all associated with decreased mortality. Radiation (AMD = − 3.64), chemotherapy (AMD = -6.35), surgery alone (AMD = -6.91), and surgery and chemotherapy (AMD = -6.74) were all associated with fewer healthcare encounters per 30 days in the last 6 months of life. Chemotherapy (AMD = -1.57), surgery alone (AMD = -1.65), and surgery and chemotherapy (AMD = -1.67) were associated with fewer palliative care visits (all p-values for estimates above < 0.05). Treatment groups were associated with lower odds of institutional death and hospitalization at EOL, and higher odds of chemotherapy at EOL.

Conclusions

Receiving cancer-directed therapies was associated with higher survival, fewer healthcare visits, lower odds of dying in an institution and hospitalization at EOL, fewer palliative care visits, and higher odds of receiving chemotherapy at EOL.

Association between Survival Duration of Older Patients with Advanced Unresectable Pancreatic Cancer and Appetite Loss: A Retrospective Cohort Study

This retrospective cohort study clarified associations between trajectories in palliative care and appetite loss among older patients with advanced unresectable pancreatic cancer and reviewed pancreatic cancer diagnosis among these populations in rural community hospitals. Patients aged >65 years and with pancreatic cancer in a rural community hospital were enrolled. The primary outcome was survival duration from the time of pancreatic cancer diagnosis. Participants were divided into those with and without appetite loss. Cumulative event-free survival rates were calculated using the Kaplan−Meier method, analyzed using the log-rank test, and stratified by factors with statistically significant between-group differences (serum albumin). The mean participant age was 84.14 (SD, 8.34) years; 31.4% were men. Significant between-group differences were noted in albumin concentration and survival duration. Kaplan−Meier curves showed a significant between-group difference in survival probability (p < 0.001). Survival duration significantly differed after stratification by albumin level (p < 0.001). Appetite loss may be a useful symptom for predicting mortality among older patients with unresectable pancreatic cancer, and hypoalbuminemia may accelerate deterioration in their conditions. Accordingly, subjective appetite loss observed by patients and families should be assessed to predict mortality, and it is advisable for physicians to promptly discuss relevant and advanced directives at appropriate timings.

The Effectiveness of Chemoradiotherapy in Elderly Patients with Pancreatic Cancer: A Population-Based Study Based on the SEER Database

INTRODUCTION

Chemotherapy (CT) is the main treatment for patients with unresected pancreatic cancer (PC). Whether the addition of radiotherapy to chemotherapy improves the prognosis of elderly patients with unresected PC is unclear. The aim of our study was to compare the efficacy of chemoradiotherapy (CRT) with chemotherapy alone in elderly patients with unresected PC.

METHODS

The clinical data of elderly patients with unresected PC who received chemotherapy between 2004 and 2017 were determined from the Surveillance, Epidemiology, and End Results (SEER) database, and the patients were divided into CT and CRT groups. The primary outcome was overall survival (OS), and secondary endpoints were cancer-specific survival (CSS) and cancer-specific mortality (CSM). Propensity matching analysis (PSM) was used to balance the differences between the two groups. OS and CSS were assessed using Kaplan-Meier analysis, while CSM was assessed using a competing risk model. Subgroup analyses were also performed, and Cox regression was used to adjust for confounding factors.

RESULTS

A total of 17,814 patients were diagnosed with PC including 14,222 who received CT alone and 3592 who received CRT. The 1-year OS of the CT and CRT groups after PSM was 30.1% and 40.8%, and the 1-year CSS was 31.4% and 42.1%, respectively. Overall, the CRT group had better OS, CSS, and CSM rates than the CT group before and after PSM (P < 0.05). After adjustment for age, sex, race, histological grade, stage, and other factors, the CRT group still had a lower risk of death than the CT group, and subgroup analysis further revealed the survival benefit of CRT in each population.

CONCLUSIONS

CRT improves the outcome of patients with non-surgical PC over 65 years of age. But prospective studies are needed to validate our results.

Impact of Microscopic Confirmation on Therapeutic Management of Pancreatic Cancer Patients: Lessons from an Italian Regional Tumor Registry

Background: Incidence of pancreatic cancer (PC) is increasing worldwide and is set to become the second leading cause of cancer-related death in 2040 with a poor 5-year overall survival (OS). The aim of this study was to analyze the impact of microscopic diagnosis of PC (MiDPC) on diagnostic−therapeutic management and outcome. Methods: The Veneto region (north-eastern Italy) has been covered by a cancer registry (CR) since 1987. Clinical and oncological data about all cases of PC in the Veneto region from 1987 were extracted from the Veneto CR database. Results: In 2018, 1340 incident cases of PC in the Veneto population were registered (4.1% of all malignant tumors), with an increasing trend in females and stable incidence in males. Five-year OS in patients with PC was 8%. The percentage of MiDPC increased from 44% in 2010 to 60% in 2018 (p = 0.001). MiDPC was higher among patients aged < 75 years old (84.4%) compared to those aged ≥75 years old (38.9%), p = 0.001. Between 2010 and 2018, a significant increase in biopsy on the primary neoplasm (24.9% vs. 13%, p < 0.001) was reported. Patients with MiDPC had higher 5-year survival than patients with no MiDPC (12.9% vs. 1.2%, p < 0.001). Conclusions: The implementation of MiDPC was essential to improve diagnostic−therapeutic pathways and consequently the survival of PC patients.

Chemotherapy effectiveness and age-group analysis of older adult patients with metastatic pancreatic cancer: A Japanese cancer registry cohort study

INTRODUCTION

Although older adults aged ≥75 years comprise a substantial proportion of patients diagnosed with pancreatic cancer (PC), the effectiveness of chemotherapy in older adults with PC remains to be established.

MATERIALS AND METHODS

This retrospective study examined the effectiveness of chemotherapy according to age in older adult patients with metastatic PC. We used a large database that combined three data sources (the hospital-based cancer registry database, Osaka Cancer Registry, and Japan's Diagnosis Procedure Combination) and extracted data from patients pathologically diagnosed with metastatic PC between 2013 and 2015 in 31 designated cancer care hospitals in Japan. Propensity score matching (PSM) was used to identify a cohort of patients with similar backgrounds. The effect of chemotherapy on overall survival (OS) was analyzed using the log-rank test.

RESULTS

Compared with 687 younger patients (<75 years old), 276 older adult patients had significant impairments in activities of daily living and poorer prognoses (6.8 vs. 4.1 months, p < 0.001), with a lower frequency of chemotherapy (81.5% vs. 55.1%; p < 0.001). PSM of older adult patients showed that chemotherapy significantly contributed to a better prognosis (best supportive care, 2.6 months vs. chemotherapy, 5.8 months, p < 0.001). Age group analysis with PSM of five-year age ranges revealed that the median OS was significantly longer in the chemotherapy group among older adult patients aged <85 years.

DISCUSSION

Chemotherapy provides a survival benefit in older adult patients with metastatic PC, and patients aged <85 years could be promising candidates for chemotherapy.

Assessing the Role of Operative Intervention in Elderly Patients With Nonfunctional Pancreatic Neuroendocrine Neoplasms

OBJECTIVES

Resection of locoregional pancreatic neuroendocrine neoplasms (PanNENs) is typically recommended, but there is a paucity of data on the management of elderly patients.

METHODS

The National Cancer Database (2004-2016) was queried for patients 80 years or older with localized PanNENs. Patients were grouped as nonoperative or operative management. Postoperative outcomes and survival were compared.

RESULTS

In total, 591 patients were included: 202 underwent resection, and 389 did not. Increasing age and pancreatic head tumors were associated with lower likelihood of resection. The overall 90-day mortality rate was 6.4%, which was higher for pancreatoduodenectomy than distal pancreatectomy (13.6% vs 5.1%, respectively). Operatively managed patients had longer median survival (80.8 vs 45.0 months, P < 0.001), and this association was independent of tumor location. On multivariable Cox regression, resection remained associated with longer survival (hazard ratio, 0.69; 95% confidence interval, 0.50-0.95). Among operatively managed patients, age and tumor location were not associated with survival; however, greater comorbidity and high-risk tumor-specific features were associated with worse survival.

CONCLUSIONS

Resection of nonfunctional PanNENs in elderly patients is associated with improved survival compared with nonoperative management. Resection could be considered in appropriate operative candidates, regardless of tumor location, but the perioperative mortality rate must be considered.

Efficacy and safety of FOLFIRINOX as second-line chemotherapy for advanced pancreatic cancer after gemcitabine-based therapy: A systematic review and meta-analysis

OBJECTIVE

To undertake a meta-analysis of the treatment effects of different second-line chemotherapy regimens compared with FOLFIRINOX (FOL [folinic acid], F [fluorouracil], IRIN [irinotecan], OX [oxaliplatin]) after failure of gemcitabine-based first-line therapy in patients with pancreatic cancer.

METHODS

This meta-analysis searched electronic databases, including Embase®, Medline, PubMed® and the Cochrane library, for eligible studies that reported the use of FOLFIRINOX and other drug regimens as second-line chemotherapy after failure of gemcitabine-based chemotherapy. Pooled analyses for progression-free survival (PFS), overall survival (OS), objective response rate (ORR), disease control rate (DCR) and grade 3/4 treatment-emergent adverse events (TRAEs) were undertaken.

RESULTS

The analysis included six studies with a total of 858 patients. Compared with the three other second-line regimens, FOLFIRINOX had a significantly longer PFS (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.52, 0.89) and OS (HR 0.71, 95% CI 0.59, 0.86); and a significantly better ORR (HR 0.43, 95% CI 0.23, 0.80) and DCR (HR 0.71, 95% CI 0.58, 0.88). However, grade 3/4 adverse events were more frequently reported in patients administered FOLFIRINOX compared with the other three regimens.

CONCLUSION

FOLFIRINOX is recommended as a second-line chemotherapy regimen for patients with pancreatic cancer that have failed on gemcitabine-based first-line therapy.Research Registry number: reviewregistry1300.

Patterns of Adjuvant Chemotherapy Use and Association With Survival in Adults 80 Years and Older With Pancreatic Adenocarcinoma

IMPORTANCE

Patients 80 years and older with pancreatic ductal adenocarcinoma (PDAC) have not consistently received treatments that have established benefits in younger older adults (aged 60-79 years), yet patients 80 years and older are increasingly being offered surgery. Whether adjuvant chemotherapy (AC) provides additional benefit among patients 80 years and older with PDAC following surgery is not well understood.

OBJECTIVE

To describe patterns of AC use in patients 80 years and older following surgical resection of PDAC and to compare overall survival between patients who received AC and those who did not.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study among patients 80 years or older diagnosed with PDAC (stage I-III) between 2004 to 2016 who underwent a pancreaticoduodenectomy at hospitals across the US reporting to the National Cancer Database.

EXPOSURES

AC vs no AC 90 days following diagnosis of PDAC.

MAIN OUTCOMES AND MEASURES

The proportion of patients who received AC was assessed over the study period. Overall survival was compared between patients who received AC and those who did not using Kaplan-Meier estimates and multivariable Cox proportional hazards regression. A landmark analysis was performed to address immortal time bias. A propensity score analysis was performed to address indication bias. Subgroup analyses were conducted in node-negative, margin-negative, clinically complex, node-positive, and margin-positive cohorts.

RESULTS

Between 2004 and 2016, 2569 patients 80 years and older (median [IQR] age, 82 [81-84] years; 1427 were women [55.5%]) underwent surgery for PDAC. Of these patients, 1217 (47.4%) received AC. Findings showed an 18.6% (95% CI, 8.0%-29.0%; P = .001) absolute increase in the use of AC among older adults who underwent a pancreaticoduodenectomy comparing rates in 2004 vs 2016. Receipt of AC was associated with a longer median survival (17.2 months; 95% CI, 16.1-19.0) compared with those who did not receive AC (12.7 months; 95% CI, 11.8-13.6). This association was consistent in propensity and subgroup analyses. In multivariable analysis, receipt of AC (hazard ratio [HR], 0.72; 95% CI, 0.65-0.79; P < .001), female sex (HR, 0.88; 95% CI, 0.80-0.96; P < .001), and surgery in the more recent time period (≥2011) (HR, 0.90; 95% CI, 0.82-0.99; P = .02) were associated with a decreased hazard of death. An increased hazard of death was associated with higher pathologic stage (stage II: HR, 1.68; 95% CI, 1.43-1.97; P < .001; stage III: HR, 2.39; 95% CI, 1.88-3.04; P < .001), positive surgical margins (HR, 1.49; 95% CI, 1.34-1.65; P < .001), length of stay greater than median (10 days) (HR, 1.17; 95% CI, 1.07-1.28; P < .001), and receipt of oncologic care at a nonacademic facilities (Community Cancer Program: HR, 1.20; 95% CI, 1.07-1.35; P < .001; Integrated Network Cancer Program: HR, 1.25; 95% CI, 1.07-1.46; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, the use of AC among patients who underwent resection for PDAC increased over the study period, yet it still was administered to fewer than 50% of patients. Receipt of AC was associated with a longer median survival.

Elderly Patients with Nondistant Metastatic Pancreatic Head Adenocarcinoma Cannot Benefit from More Radical Surgery

BACKGROUND

The incidence of pancreatic cancer continues to rise globally, with pancreatic head cancer accounting for nearly 60-70%. Pancreatic head cancer occurs mainly in people over the age of 60, and its morbidity and mortality increase with age. We investigated whether these elderly patients with nondistant metastases would benefit more from expanded pancreaticoduodenectomy (EPD) compared with standard pancreaticoduodenectomy (SPD).

METHODS

3317 elderly patients with pancreatic head cancer from the SEER database were included in the study based on the inclusion and exclusion criteria. These patients were divided into a nonsurgical group and surgical group (including EPD and SPD). Univariate and multivariate Cox proportional hazards models were applied to identify the independent risk factors for cancer-specific survival (CSS). The survival differences between the nonsurgical group and surgical group were compared. Propensity score matching (PSM) methods were applied to balance covariates and reduce the interference of confounding variables. The two groups of patients were matched in a 1 : 1 ratio, and the covariates between the two groups were compared to verify the matching validity. The survival difference in different groups was compared after the matching analysis.

RESULTS

3317 enrolled patients were divided into the surgical group (n = 984) and nonsurgical group (n = 2333). Before PSM, there were significant differences in overall survival (OS) and CSS between the nonsurgical group and surgical group (median OS: 8 months vs. 20 months, P < 0.001; median CSS: 8 months vs. 22 months, P < 0.001). The multivariate CSS Cox regression analysis demonstrated surgery is an independent risk factor. However, no significant differences were founded between the SPD and EPD groups (median OS: 20 months vs. 22 months, P=0.636; median CSS: 22 months vs. 22 months, P=0.270). After PSM, there were also no significant differences in OS and CSS between the SPD and EPD groups (median OS: 23 months vs. 18 months, P=0.415; median CSS: 26 months vs. 18 months, P=0.329).

CONCLUSION

This study uses PSM to evaluate the effects of EPD and SPD for elderly patients with nondistant metastatic pancreatic head adenocarcinoma. It found that surgery is an independent prognostic factor, but expanded surgery has no survival advantage for these patients, whereas SPD provides a better survival advantage than EPD. SPD is a reasonable treatment option for these patients.

BDNF Acts as a Prognostic Factor Associated with Tumor-Infiltrating Th2 Cells in Pancreatic Adenocarcinoma

Pancreatic adenocarcinoma (PAAD) is an extremely lethal disease worldwide. Brain-derived neurotrophic factor (BDNF) is a critical member of the neurotrophin polypeptide superfamily that plays an important role in multiple cancers. However, the association among BDNF expression, tumor immunity, and PAAD prognosis remains unclear. BDNF expression and its influence on patient prognosis were explored based on The Cancer Genome Atlas, Cancer Cell Line Encyclopedia, Genotype-Tissue Expression, and Kaplan-Meier plotter. Gene set enrichment analysis was performed to understand the biological roles of BDNF. The role of BDNF in tumor-infiltrating immune cells was determined using the Tumor Immune Estimation Resource database and the single-sample gene set enrichment analysis and xCell algorithm. The correlation among BDNF and chemokines, chemokine receptors, chemotherapeutic efficacy, and immune checkpoints was analyzed based on RStudio. BDNF expression was remarkably higher in PAAD compared to their paired normal tissues, and high BDNF expression was associated with unfavorable prognosis. Enrichment analysis revealed that BDNF was significantly enriched in major oncogenic pathways in PAAD. BDNF expression was positively correlated with immune infiltration, especially Th2 cells. Moreover, BDNF expression was positively correlated with Th2 cell-related chemokine/chemokine receptors, indicating that BDNF might modulate the migration of Th2 cells in PAAD. We also found that BDNF expression was correlated with high chemotherapeutics sensitivity and highly expressed immune checkpoints, making it a valuable biomarker in predicting the therapeutic benefits for chemotherapy and immunotherapy in cancer patients. In summary, BDNF might affect patient prognosis by interacting with tumor-infiltrating Th2 cells, thus serving as a potential prognostic biomarker in PAAD.

Nuclear receptor subfamily 5 group A member 2 (NR5A2): role in health and diseases

Nuclear receptors are the regulatory molecules that mediate cellular signals as they interact with specific DNA sequences. NR5A2 is a member of NR5A subfamily having four members (Nr5a1-Nr5a4). NR5A2 shows involvement in diverse biological processes like reverse cholesterol transport, embryonic stem cell pluripotency, steroidogenesis, development and differentiation of embryo, and adult homeostasis. NR5A2 haploinsufficiency has been seen associated with chronic pancreatitis, pancreatic and gastrointestinal cancer. There is a close relationship between the progression of pancreatic cancer from chronic pancreatitis, NR5A2 serving a common link. NR5A2 activity is regulated by intracellular phospholipids, transcriptional coregulators and post-translational modifications. The specific ligand of NR5A2 is unknown hence called an orphan receptor, but specific phospholipids such as dilauroyl phosphatidylcholine and diundecanoyl phosphatidylcholine act as a ligand and they are established drug targets in various diseases. This review will focus on the NR5A2 structure, regulation of its activity, and role in biological processes and diseases. In future, need more emphasis on discovering small molecule agonists and antagonist, which act as a drug target for therapeutic applications.

Reviewing the Outcomes of Different Treatment Approaches in Elderly Pancreatic Cancer Patients

OBJECTIVES

The incidence of pancreatic cancer is age dependent. Ninety percent of new diagnoses occur in patients older than 55 years. Despite the association with age and cancer, elderly patients are historically underrepresented in clinical trials. Thus, optimal management of elderly patients has a lack of data. The purpose of this retrospective study was to investigate the outcomes of palliative chemotherapy in elderly patients with pancreatic cancer compared with supportive care alone.

METHODS

Unicentric data were reviewed on all elderly patients (defined as age >65 years) with a diagnosis of pancreatic cancer from 2008 through 2019 to compare outcomes in those who received chemotherapy versus supportive care alone.

RESULTS

The study reviewed 665 patients with a median age of 75 years (mean, 75.7 years) and average Charlson Comorbidity Score of 5.74. Of them, 291 received chemotherapy and 363 received supportive care only. Chemotherapy was associated with a median overall survival of 250 versus 93 days with supportive care (P < 0.0001). Analysis showed improved survival for all age ranges, cancer stages, and Charlson Comorbidity Scores.

CONCLUSIONS

Elderly pancreatic cancer patients can benefit from palliative chemotherapy, and it should be considered, especially in patients with fewer medical comorbidities and better functional status.

Prognostic significance of skeletal muscle decrease in unresectable pancreatic cancer: Survival analysis using the Weibull exponential distribution model

BACKGROUND/OBJECTIVES

Decrease in skeletal muscle mass and function is associated with a poor prognosis following surgical resection of pancreatic ductal adenocarcinomas (PDAs). This study evaluated whether skeletal muscle mass decrease affects PDA outcomes.

METHODS

Data of 112 patients with advanced and unresectable PDA who underwent chemotherapy in a single institution were retrospectively analyzed. Information on age, sex, hematological investigations, including systemic inflammation-based markers and nutritional assessment biomarkers, and imaging parameters of skeletal muscle mass and visceral adipose tissue were retrieved from the patients' medical records. The efficiency of the Cox, Weibull, and standardized exponential models were compared using hazard ratios and the Akaike Information Criterion (AIC).

RESULTS

Results from the Weibull, Cox, and standardized exponential model analyses indicated that low skeletal muscle mass, Eastern Cooperative Oncology Group performance status (PS), and the requirement of biliary drainage were associated with the highest risk of death, followed by carcinoembryonic antigen (CEA) levels and the presence of ascites. The AIC value from the four significant parameters was lowest for the Weibull-exponential distribution (222.3) than that of the Cox (653.7) and standardized exponential models (265.7). We developed a model for estimating the 1-year survival probability using the Weibull-exponential distribution.

CONCLUSIONS

Low-skeletal muscle index, PS, requirement of biliary drainage, CEA levels, and presence of ascites are independent factors for predicting poor patient survival after chemotherapy. Improved survival modeling using a parametric approach may accurately predict the outcome of patients with advanced-stage PDA.

Safe and efficient 2D molybdenum disulfide platform for cooperative imaging-guided photothermal-selective chemotherapy: A preclinical study

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Safe and efficient platform of TOS married MoS₂ is synthesized by judicious designed for multimode theranostics of ovarian carcinoma.

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A photothermal conversion efficiency of 65.3% of the platform is higher than that of other materials reported elsewhere.

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Highly efficient photothermal ablation under safe irradiation and significantly improved selective chemotherapy for tumor.

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Synergistic therapy, suppressed recurrence, and negligible side effects enable the prominent survival rate of 100% over 91 days for the tumor-bearing mice.

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A promising candidate for precise nanomedicines in clinical translation.

Introduction

The striking imbalance between the ever-increasing amount of nanomedicines and low clinical translation of products has become the focus of intense debate. For clinical translation, the critical issue is to select the appropriate agents and combination regimen for targeted diseases, not to prepare increasingly complex nanoplatforms.

Objectives

A safe and efficient platform, α-tocopheryl succinate (α-TOS) married 2D molybdenum disulfide, was devised by a facile method and applied for cooperative imaging-guided photothermal-selective chemotherapy of ovarian carcinoma.

Methods

A novel platform of PEGylated α-TOS and folic acid (FA) conjugated 2D MoS₂ nanoflakes was fabricated  for the cooperative multimode computed tomography (CT)/photoacoustic (PA)/thermal imaging-guided photothermal-selective chemotherapy of ovarian carcinoma.

Results

The photothermal efficiency (65.3%) of the platform under safe near-infrared irradiation is much higher than that of other photothermal materials reported elsewhere. Moreover, the covalently linked α-TOS renders platform with selective chemotherapy for cancer cells. Remarkably, with these excellent properties, the platform can be used to completely eliminate the solid tumor by safe photothermal therapy, and then kill the residual cancer cells by selective chemotherapy to prevent tumor recurrence. More significantly, barely side effects occur in the whole treatment process. The excellent efficacy and safety benefits in vivo lead to the prominent survival rate of 100% over 91 days.

Conclusion

The safe and efficient platform might be a candidate of clinical nanomedicines for multimode theranostics. This study demonstrates an innovative thought in precise nanomedicine regarding the design of next generation of cancer theranostic protocol for potential clinical practice.

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Pancreatic Cancer

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Pancreatic cancer is an increasing cause of cancer mortality and has wide variation in treatment and care in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must be carried out only in pancreatic cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

The potential use for patient reported outcome measures in people with pancreatic cancer, with a specific focus on older patients

Pancreatic cancer is one of the most lethal malignancies and is characterised by high-unmet physical and psychological supportive care needs. Patient Reported Outcome Measures (PROMs) represent a patient centred approach to address the high unmet supportive care need and improve the quality of care. PROMs have the potential to inform patients about the quality of life and symptom trajectory for different treatment approaches so that they can fully participate in shared decisions about treatment. Embedding the collection of PROMs into routine practice alongside clinical alerts and directed symptom interventions is acceptable and feasible for people with pancreatic cancer and has the potential to reduce symptom burden. There is also limited information on survival, quality of life and the holistic impact of treatment for older pancreatic cancer patients, therefore, PROMs provide an opportunity to understand the impact of treatment on older patients and better inform shared treatment decision-making.

Clinical features and prognostic factors of elderly patients with metastatic pancreatic cancer: a population-based study

The aim of this study was to evaluate the clinical features and prognostic factors of elderly patients with metastatic pancreatic cancer. Patients diagnosed with metastatic pancreatic cancer between 2004 and 2014 were identified from the Surveillance Epidemiology and End Results database. Clinical characteristics and prognostic factors in elderly patients with metastatic pancreatic cancer were examined. A total of 10784 metastatic pancreatic cancer patients between 65 and 80 years old were included and divided into three age groups. Elderly metastatic pancreatic cancer patients differed from younger patients in many aspects, including marital status, race, sex, T stage, N stage, treatment regimen, prognosis, cause of death, and metastatic characteristics (P<0.001). An analysis of prognostic factors showed that chemotherapy, as the main treatment for elderly patients, can significantly improve prognosis, while surgery can improve the prognosis of patients between 65 and 80 years old. Other factors, including sex, marital status, T stage, and site of metastasis, had different effects on patients in different age groups. Elderly patients with metastatic pancreatic cancer are a special group of individuals whose clinical characteristics and prognostic factors are different from those of younger patients, and these patients require special treatment and attention.

Comprehensive pharmacogenetic analysis of DPYD, UGT, CDA, and ABCB1 polymorphisms in pancreatic cancer patients receiving mFOLFIRINOX or gemcitabine plus nab-paclitaxel

Modified FOLFIRINOX (mFOLFIRINOX) and gemcitabine + nab-paclitaxel (GemNab) regimens represent a standard treatment in advanced pancreatic cancer (aPC). DPYD and UGT1A1 variants are relevant predictors of fluoropyrimidine and irinotecan-associated adverse events (AEs). Furthermore, data about the associations between polymorphisms in ABCB and CDA genes and GemNab-related toxicities are still controversial. The present study analyzes the association between DPYD, UGT, ABCB1, CDA variants, and AEs in aPC patients (pts) treated with mFOLFIRINOX or GemNab. Blood samples collected from 104 aPC pts treated with mFOLFIRINOX and 63 with GemNab were tested for DPYD c.1679T>G, IVS14+1G>A, c.2194G>A, c.2846A>T, UGT1A1*28, CDA c.79A>C, and ABCB1 c.1236C>T, c.2677G>T/A, c.3435C>T by real-time PCR and automatic sequencing. In mFOLFIRINOX cohort, DPYD IVS14+1GA genotype was associated with G4 hematological AEs, while the UGT1A1*28 significantly correlated with the risk of thrombocytopenia (p = 0.006). In the GemNab cohort, a significant association between CDA c.79CC and high-grade nausea was observed (p = 0.002). Moreover, the presence of at least a mutant allele in ABCB1 increased the risk of overall hematological AEs (p = 0.01), both further strengthened by the presence of CDA c.79CC (p = 0.0002). DPYD IVS14+1A allele is confirmed to be associated with fluoropyrimidine life-threatening toxicities, and UGT1A1*28 is related with a higher risk of hematologic AEs following irinotecan treatment. CDA c.79C and ABCB1 c.1236T, c.2677T/A, and c.3435T mutant alleles are predictive biomarkers of GemNab-related AEs. All these variants should be considered in aPC pts candidate to mFOLFIRINOX or GemNab treatments.

Multidrug regimens for treatment of older patients with metastatic pancreatic cancer

BACKGROUND AND AIMS

Older patients with metastatic pancreatic adenocarcinoma (MPDAC) are under-represented in clinical trials.

METHODS

Our single-center, retrospective study enrolled MPDAC patients ≥ 70 treated with chemotherapy RESULTS: 105 patients were divided in groups based on the received treatments: 44 gemcitabine or capecitabine monotherapy (A), 34 nabpaclitaxel-gemcitabine (B) 27 4-drugs combinations (gemcitabine, cisplatin, capecitabine plus either nab-paclitaxel or epirubicin or docetaxel) (C). Group A: median age was 78 (70-87) and Karnofsky performance status (KPS) ≥80 was found in 84% of patients; Group B: median age 77 (71-84) and KPS ≥ 80 in 88% of patients; Group C: median age 73 (70-78) and KPS ≥ 80 in 93% of patients. Median OS was 7.9, 11.7 and 14.2 months in group A, B and C respectively; 1 and 2-year OS were 27% and 8% in group A; 44% and 5% in group B; 52% and 22% in group C. When lung metastatic only patients were excluded, patients <75 and ≥ 75 had similar OS in group A (6.4 vs 5.6 months) and in group B (12.3 vs 11.1 months). In group B grade 3 thrombocytopenia, fatigue and peripheral neuropathy were more frequent in patients ≥ 75.

CONCLUSIONS

In older patients, combination chemotherapy shows acceptable feasibility and promising efficacy.

The treatment and survival of elderly patients with locally advanced pancreatic cancer: A post-hoc analysis of a multicenter registry

BACKGROUND

The treatment options for patients with locally advanced pancreatic cancer (LAPC) have improved in recent years and consequently survival has increased. It is unknown, however, if elderly patients benefit from these improvements in therapy. With the ongoing aging of the patient population and an increasing incidence of pancreatic cancer, this patient group becomes more relevant. This study aims to clarify the association between increasing age, treatment and overall survival in patients with LAPC.

METHODS

Post-hoc analysis of a multicenter registry including consecutive patients with LAPC, who were registered in 14 centers of the Dutch Pancreatic Cancer Group (April 2015-December 2017). Patients were divided in three groups according to age (<65, 65-74 and ≥75 years). Primary outcome was overall survival stratified by primary treatment strategy. Multivariable regression analyses were performed to adjust for possible confounders.

RESULTS

Overall, 422 patients with LAPC were included; 162 patients (38%) aged <65 years, 182 patients (43%) aged 65-74 and 78 patients (19%) aged ≥75 years. Chemotherapy was administered in 86%, 81% and 50% of the patients in the different age groups (p<0.01). Median overall survival was 12, 11 and 7 months for the different age groups (p<0.01).Patients treated with chemotherapy showed comparable median overall survival of 13, 14 and 10 months for the different age groups (p=0.11). When adjusted for confounders, age was not associated with overall survival.

CONCLUSION

Elderly patients are less likely to be treated with chemotherapy, but when treated with chemotherapy, their survival is comparable to younger patients.

Ancistrobrevidines A-C and related naphthylisoquinoline alkaloids with cytotoxic activities against HeLa and pancreatic cancer cells, from the liana Ancistrocladus abbreviatus

From the leaves of Ancistrocladus abbreviatus (Ancistrocladaceae), six 5,1'-coupled naphthyldihydroisoquinoline alkaloids were isolated, ancistrobrevidines A-C (5-7), 5-epi-dioncophyllidine C₂ (10), 6-O-methylhamatinine (8), and 6-O-methylancistectorine A₃ (9); the two latter compounds were already known from related plants. Most strikingly, this series comprises alkaloids belonging to three different subclasses of naphthylisoquinolines. Ancistrobrevidine C (7) and the alkaloids 8 and 9, displaying the S-configuration at C-3 and an oxygen function at C-6, are three further representatives of the large subgroup of 5,1'-coupled Ancistrocladaceae-type compounds found in nature. 5-epi-Dioncophyllidine C₂ (10), lacking an oxygen function at C-6 and having the R-configuration at C-3, is only the third representative of a 5,1'-linked Dioncophyllaceae-type naphthylisoquinoline. Likewise rare are 5,1'-coupled hybrid-type alkaloids, which are 6-oxygenated and 3R-configured. The ancistrobrevidines A (5) and B (6) are the only second and third examples of such 5,1'-linked naphthylisoquinolines in Ancistrocladus species showing the landmarks of both, Ancistrocladaceae- and Dioncophyllaceae-type naphthylisoquinolines. In the roots of A. abbreviatus, two further unprecedented 5,1'-coupled alkaloids were discovered, ancistrobreviquinones A (11) and B (12), consisting of a 3,4-naphthoquinone portion coupled to a tetrahydroisoquinoline subunit. They are the very first quinoid naphthylisoquinolines possessing an ortho-diketone entity. Ancistrobrevidine C (7) exerted pronounced antiproliferative activities against HeLa cervical cancer cells and preferential cytotoxicity towards PANC-1 human pancreatic cancer cells under nutrient-deprived conditions following the antiausterity approach. Moreover, 7 suppressed the migration of PANC-1 cells and significantly inhibited colony formation under nutrient-rich conditions in a concentration-dependent manner, and induced dramatic alteration in cell morphology, leading to cell death.

Can Elderly Patients With Pancreatic Cancer Gain Survival Advantages Through More Radical Surgeries? A SEER-Based Analysis

Background and Aims

In recent years, the best treatment method for pancreatic cancer in elderly patients has remained controversial. Surgery is the main treatment modality for pancreatic cancer. This study aimed to determine whether elderly patients with pancreatic cancer can gain survival advantages through more active and radical surgical treatment and evaluate the best treatment method and potential prognostic factors.

Methods

From the Surveillance, Epidemiology, and End Results program (SEER) database, 10,557 elderly patients (aged ≥65 years) with pancreatic cancer were included as Cohort 1, and Propensity Score Matching (PSM) evaluation was performed to generate Cohort 2 (424 pairs). Overall Survival (OS) and Cause-Specific Survival (CSS) were determined using Kaplan-Meier survival curves, and differences were assessed using the Log-rank test. Multivariate logistic regression analysis and the forest plot of hazard ratio (HR) was made to assess the association between potential prognostic factors, including surgery and different surgical methods, and survival in elderly patients.

Results

We identified 10,557 eligible patients with pancreatic cancer, who formed Cohort 1. The total OS and CSS in the surgery group were significantly higher than those in the non-surgery group (P < 0.001). Age, stage (AJCC 8th), grade, lymph node metastasis, radiation, chemotherapy, and surgical methods were independent factors affecting the prognosis of elderly patients. In Cohort 2, Total pancreatectomy (Total PT) had the lowest risk ratio (HR = 0.31, P < 0.001) and longest median CSS (18.000 months), while Extension Total pancreatectomy (Ex-Total PT, HR = 0.34, P < 0.001) showed the lower median CSS (17.000 months) and median OS (14.000 months). Partial pancreatectomy (Partial PT, HR = 0.46, P < 0.001) showed the lowest median CSS (13.000 months) and median OS (12.000 months), although they were still higher than the median CSS (6.000 months) and median OS (5.000 months) in the non-surgery group.

Conclusions

Based on the SEER database, surgical treatment is an independent prognostic factor in elderly patients with pancreatic cancer. Compared with other surgical methods, Total PT can offer elderly patients the best survival advantages. However, Ex-Total PT, a more radical method, does not seem to be the best treatment option for the survival and benefit of elderly patients.

Advanced Pancreatic Ductal Adenocarcinoma: Moving Forward

Globally, the death rate of pancreatic ductal adenocarcinoma (PDAC) has doubled over 30 years and is likely to further increase, making PDAC a leading cause of cancer-related death in the coming years. PDAC is typically diagnosed at an advanced stage, and modified FOLFIRINOX or nab-paclitaxel and gemcitabine are the mainstay of systemic therapy. For elderly patients with good performance status, low-dose treatment can preserve quality of life without compromising cancer control or survival. Maintenance therapy should be considered in PDAC patients achieving disease control with systemic therapy. In particular, olaparib has demonstrated a progression-free survival benefit of 3.6 months in a subgroup of PDAC patients with germline BRCA1/2 mutations (ca. 10% of all PDAC). Pancreatic enzyme replacement therapy is often omitted in the treatment of patients with PDAC, with possibly deleterious consequences. Small intestinal bacterial overgrowth is highly prevalent in patients with PDAC and should be considered in the diagnostic algorithm of PDAC patients with bloating and diarrhea. Rivaroxaban has been associated with a reduced risk of thrombosis without an increase in major bleeding events, and its use should be considered in every patient with advanced PDAC undergoing systemic therapy.

Cyclodextrin as a magic switch in covalent and non-covalent anticancer drug release systems

Cancer has been a threat to human health, so its treatment is a huge challenge to the present medical field. One of commonly used methods is the controlled release of anticancer drug to reduce the dose for patients, increase the stability of drug treatment and minimize side effects. Cyclodextrin is a kind of cyclic oligosaccharide produced by amylase hydrolysis. Because cyclodextrin contains a cavity structure and active hydroxyl groups, it has a positive effect on the study of the controlled release of anticancer drugs. This article reviews the controlled release of current anticancer drugs based on cyclodextrins as a "flexible switch", and discusses the classification of different types of release systems, highlighting their role in cancer treatment. Moreover, the opportunities and challenges of cyclodextrin as a magic switch in the controlled release of anticancer drugs are discussed.

New Treatment Strategies for Metastatic Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is typically diagnosed at an advanced stage, with systemic therapy being the mainstay of treatment. Survival continues to be limited, typically less than 1 year. The PDAC microenvironment is characterized by a paucity of malignant epithelial cells, abundant stroma with predominantly immunosuppressive T cells and myelosuppressive-type macrophages (M2), and hypovascularity. The current treatment options for metastatic PDAC are modified (m)FOLFIRINOX /FOLFIRINOX or nab-paclitaxel and gemcitabine in patients with good performance status (PS) (ECOG 0-1/KPS 70-100%) and gemcitabine with or without a second agent for those with ECOG PS 2-3. New therapies are emerging, and the current guidelines endorse both germline and somatic testing in PDAC to evaluate actionable findings. Important themes related to new therapeutic approaches include DNA damage repair strategies, immunotherapy, targeting the stroma, and cancer-cell metabolism. Targeted therapy alone (outside small genomically defined subsets) or in combination with standard cytotoxic therapy, thus far, has proven disappointing in PDAC; however, novel therapies are evolving with increased integration of genomic profiling along with a better understanding of the tumor microenvironment and immunology. A small but important sub-group of patients have some of these agents available in the clinics for use. Olaparib was recently approved by the US Food and Drug Administration for maintenance therapy in germline BRCA1/2 mutated PDAC following demonstration of survival benefit in a phase 3 trial. Pembrolizumab is approved for patients with defects in mismatch repair/microsatellite instability. PDAC with wild-type KRAS represents a unique subgroup who have enrichment of potentially targetable oncogenic drivers. Small-molecule inhibitors including ERBB inhibitors (e.g., afatinib, MCLA-128), TRK inhibitors (e.g., larotrectinib, entrectinib), ALK/ROS inhibitor (e.g., crizotinib), and BRAF/MEK inhibitors are in development. In a small subset of patients with the KRASG12C mutation, a KRASG12C inhibitor, AMG510, and other agents are being investigated. Major efforts are underway to effectively target the tumor microenvironment and to integrate immunotherapy into the treatment of PDAC, and although thus far the impact has been modest to ineffective, nonetheless, there is optimism that some of the challenges will be overcome.

GEM on proliferation and apoptosis of childhood AL cells through inhibiting c-myc expression by upregulating miR-125a-3p

Effect of gemcitabine (GEM) on proliferation and apoptosis of childhood acute leukemia (AL) cells and the mechanism of action were investigated. Bone marrow and peripheral blood of 18 newly diagnosed children with childhood AL admitted to Yidu Central Hospital of Weifang were selected, and the miR-125a-3p level in peripheral blood of healthy children and children with AL was detected by quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Leukemia cells from the bone marrow of children with AL were primarily cultured and purified to observe the morphology. miR-125a-3p mimic was transfected into childhood AL cells. The cells were randomly divided into three groups: control group, GEM group and GEM + miR-125a-3p mimic group. 5-ethynyl-2′-deoxyuridine (EdU) staining assay was chosen to detect the proliferation of childhood AL cells in each group. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining assay was adopted to determine apoptosis of childhood AL cells. The protein level of c-myc was measured via western blotting. Compared with that in the healthy children, the level of miR-125a-3p in the peripheral blood of children with AL was remarkably decreased. Compared with those in the control group, GEM inhibited proliferation and promoted apoptosis of childhood AL cells, and impeded the protein expression of c-myc in these cells. Compared with those in the GEM group, GEM + miR-125a-3p mimic notably reduced the proliferation and enhanced apoptosis of cells, and the protein expression of c-myc in cells was overtly reduced. The level of miR-125a-3p in peripheral blood of children with AL is obviously decreased. It is suggested in this study that GEM can inhibit the proliferation and promote apoptosis of childhood AL cells, and the mechanism may be related to upregulated miR-125a-3p inhibiting the expression of c-myc.

The In Vitro Anticancer Activity and Potential Mechanism of Action of 1-[(1R,2S)-2-fluorocyclopropyl]Ciprofloxacin-(4-methyl/phenyl/benzyl-3- aryl)-1,2,4-triazole-5(4H)-thione Hybrids

AIM

Development of 1-[(1R, 2S)-2-fluorocyclopropyl]ciprofloxacin-1,2,4-triazole-5(4H)- thione hybrids as potential dual-acting mechanism anticancer agent to overcome the drug resistance.

BACKGROUND

Chemotherapy is an essential tool for the treatment of lung and female breast cancers, and numerous anticancer agents have been launched for this purpose. However, the clinical outcomes of chemotherapy are usually far from satisfactory due to the side effects and resistance to chemotherapeutic drugs. Thus, it is urgent to develop novel anti-lung and anti-breast cancer agents.

OBJECTIVE

The primary objective of this study was to evaluate the potential of bis-isatin scaffolds with alkyl/ether linkers between the two isatin moieties against different human breast cancer cell lines including A549, MCF-7 and their drug-resistant counterparts A549/CDDP, MCF-7/ADM cells.

METHODS

The 1-[(1R, 2S)-2-fluorocyclopropyl]ciprofloxacin-(4-methyl/phenyl/benzyl-3-aryl)-1,2,4- triazole-5(4H)-thione hybrids were screened for their in vitro activity against drug-sensitive lung (A549), breast (MCF-7) and their drug-resistant counterparts A549/CDDP (cisplatin-resistant), MCF- 7/ADM (doxorubicin-resistant) cancer cell lines by MTT assay. The inhibitory activity of these hybrids against topoisomerase II and EGFR was also evaluated to investigate the potential mechanism of action of these hybrids.

RESULTS

The most prominent hybrid 7k (IC50: 37.28-49.05 µM) was comparable to Vorinostat against A549 and A549/CDDP lung cancer cells, and was 2.79-2.94 times more active than Vorinostat against MCF-7 and MCF-7/ADM breast cancer cell lines. Moreover, hybrid 7k (IC50: 8.6 and 16.4 µM) also demonstrated dual inhibition against topoisomerase II and EGFR.

CONCLUSION

The 1-[(1R, 2S)-2-fluorocyclopropyl]ciprofloxacin-1,2,4-triazole-5(4H)-thione hybrids possess equally activity against both drug-sensitive cancer cells and their drug-resistant counterparts, and the majority of them were no inferior to the reference Vorinostat. The mechanistic study revealed that these hybrids could inhibit both topoisomerase II and EGFR, so these hybrids can be developed as dual-acting mechanism anticancer agents.

Analysis of lncRNA-mRNA networks after MEK1/2 inhibition based on WGCNA in pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDA) responds poorly to treatment. Efforts have been exerted to prolong the survival time of PDA, but the 5-year survival rates remain disappointing. Understanding the molecular mechanisms of PDA development is significant. MEK/ERK pathway signaling has been proven to be important in PDA. lncRNA-mRNA networks have become a vital part of molecular mechanisms in the MEK/ERK pathway. Herein, weighted gene coexpression network analysis was used to investigate the coexpressed lncRNA-mRNA networks in the MEK/ERK pathway based on GSE45765. Differently expressed long noncoding RNA (lncRNA) and messenger RNA (mRNA) were found and 10 modules were identified based on coexpression profiles. Gene ontology and Kyoto Encyclopedia of Genes and Genomes were then performed to analyze the coexpressed lncRNA and mRNA in different modules. PDA cells and tissues were used to validate the analysis results. Finally, we found that NONHSAT185150.1 and B4GALT6 were negatively correlated with MEK1/2. By analyzing GSE45765, the genome-wide profiles of lncRNA-mRNA network after MEK1/2 was established, which might aid the development of drug-targeting MEK1/2 and the investigation of diagnostic markers.

First line nab-paclitaxel plus gemcitabine in elderly metastatic pancreatic patients: a good choice beyond age

Background

Nab-paclitaxel plus gemcitabine represents one of the standard regimens for first line treatment of metastatic pancreatic cancer (mPC). Few data are available on nab-paclitaxel plus gemcitabine in geriatric population. Our study aims to show whether this schedule can be feasible in the elderly as first-line treatment for mPC.

Methods

We retrospectively analyzed the data of 64 mPC patients (≥65 years old) treated according to the MPACT schedule.

Results

Median age was 69.5 years (range, 65-80 years); after a median of 5 cycles administered (range, 1-12), the most common adverse events (AEs) were grade 2 alopecia (46.9%), anemia (17.2%) and hypertransaminasemia (10.9%); all grades neutropenia occurred in 20.3% of pts. Global incidence of grade 3 and 4 toxicities were 26.5% and 0%, respectively, and no patients stopped treatment due to unacceptable toxicity. Stable disease (SD) was observed in 31.2% of patients, with a disease control rate (DCR) and overall response rate of 57.8% and 26.6%, respectively. After a median follow-up of 18 months, median progression free survival (PFS) was 8 months (95% CI: 6.3-9.6) and median OS was 12.0 months (95% CI: 8.4-15.6). The univariate analysis for overall survival (OS) showed that only ECOG performance status was an independent prognostic factor for survival.

Conclusions

Nab-paclitaxel plus gemcitabine schedule is feasible and effective in the "daily clinical practice" geriatric population.

An update on treatment options for pancreatic adenocarcinoma

Pancreatic cancer is one of the most lethal solid organ tumors. Due to the rising incidence, late diagnosis, and limited treatment options, it is expected to be the second leading cause of cancer deaths in high income countries in the next decade. The multidisciplinary treatment of this disease depends on the stage of cancer at diagnosis (resectable, borderline, locally advanced, and metastatic disease), and combines surgery, chemotherapy, chemoradiotherapy, and supportive care. The landscape of multidisciplinary pancreatic cancer treatment is changing rapidly, especially in locally advanced disease, and the number of treatment options in metastatic disease, including personalized medicine, innovative targets, immunotherapy, therapeutic vaccines, adoptive T-cell transfer, or stemness inhibitors, will probably expand in the near future. This review summarizes the current literature and provides an overview of how new therapies or new therapeutic strategies (neoadjuvant therapies, conversion surgery) will guide multidisciplinary disease management, future clinical trials, and, hopefully, will increase overall survival.

Basket Trials for Intractable Cancer

Currently, genomic characterization has become standard of care for tumor types such as non-small cell lung cancer, breast cancer, melanoma, and colorectal cancer. A deep understanding of genomic alterations in different tumor types would help identify potentially actionable genomic changes which occur across a wide variety of tumor types. A basket trial is a new type of clinical trial for which eligibility is based on the presence of a specific genomic alteration, irrespective of histology. Basket trials are phase II screening trials for the off-label use of a targeted drug in patients with the same genomic alterations for which it was approved. Intractable cancer refers to a type or condition of cancer which is unresponsive or resistant to treatment; intractable cancers may be classified into five subtypes as follows: hard-to-treat condition of common advanced cancer after multiple-line therapy, rare cancer in which no standard of care has been recommended, advanced cancer in which standard of care does not work well, cancer accompanied with organ dysfunction, and cancers in older or younger cancer patients. Previous studies have demonstrated that in basket trials, genomic-guided therapy yields clinical benefits in intractable cancer, thereby providing novel insights into the optimal clinical management of such cancers. In this review, we describe a novel way to classify intractable cancer, and summarize the current knowledge on such cancers. We additionally provide information on the role of basket trials in intractable cancer.