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Wijetunga AR, Chua TC, Nahm CB, Pavlakis N, Clarke S, Chan DL, Diakos C, Maloney S, Ashrafi-Zadeh A, Kneebone A, Hruby G, Jamieson NB, Gill A, Mittal A, Samra JS. Survival in borderline resectable and locally advanced pancreatic cancer is determined by the duration and response of neoadjuvant therapy. Eur J Surg Oncol 2021; 47:2543-2550. [PMID: 33952409 DOI: 10.1016/j.ejso.2021.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/04/2021] [Accepted: 04/05/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pancreatic cancer is the 8th commonest cancer and the 5th commonest cause of cancer-related death in Australia, with a 9% average 5-year survival. This study aims to investigate the effects of neoadjuvant treatment on overall survival (OS) and recurrence-free survival (RFS) in borderline resectable (BRPC) and locally advanced (LAPC) pancreatic adenocarcinoma followed by curative resection. MATERIALS AND METHODS Prospectively-collected demographic, medical, surgical and pathological data of patients with BRPC and LAPC treated with both neoadjuvant therapy (NAT) and surgery at a single tertiary referral centre in Australia were reviewed and analysed. RESULTS Between 2012 and 2018, 60 patients, 34 with BRPC and 26 with LAPC, were treated with NAT followed by curative resection. The commonest neoadjuvant chemotherapy regimens were Gemcitabine + Abraxane (51.7%) and FOLFIRINOX (35.0%), with 48.3% of patients additionally receiving neoadjuvant radiotherapy. Median RFS was 30 months and median OS was 35 months. On multivariable analysis, inferior OS was predicted by enlarged loco-regional lymph nodes on initial computed tomography (p = 0.032), larger tumour size post-NAT (p = 0.006) and Common Terminology Criteria for Adverse Events post-NAT toxicity greater than grade 2 (p = 0.015). LAPC patients received more neoadjuvant chemotherapy (p = 0.008) and radiotherapy (p = 0.021) than BRPC and achieved a superior pathological response (p = 0.010). CONCLUSION Patients who respond to NAT likely have a favourable disease biology and will progress well following resection. It is these patients who should be selected for more aggressive upfront management, and those with resistant disease should be spared from high-risk surgery.
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Affiliation(s)
| | - Terence C Chua
- School of Medicine, Griffith University, Gold Coast, QLD, Australia; Department of Surgery, QE II Jubilee Hospital, Brisbane, QLD, Australia
| | - Christopher B Nahm
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Hepatopancreatobiliary Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Nick Pavlakis
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia
| | - Stephen Clarke
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia
| | - David L Chan
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia
| | - Connie Diakos
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia
| | - Sarah Maloney
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Amir Ashrafi-Zadeh
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Andrew Kneebone
- Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia; Department of Radiation Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - George Hruby
- Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia; Department of Radiation Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Nigel B Jamieson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Anthony Gill
- Sydney Medical School, The University of Sydney, Sydney, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW, Australia; NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Anubhav Mittal
- Sydney Medical School, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia; Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Jaswinder S Samra
- Sydney Medical School, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia; Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
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Wijetunga AR, Lee A, Jayamanne DT. PEG site metastasis in oropharyngeal squamous cell carcinoma managed with cetuximab and radiotherapy: A case report. Curr Probl Cancer 2021; 45:100700. [PMID: 33454088 DOI: 10.1016/j.currproblcancer.2020.100700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/02/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
Percutaneous endoscopic gastrostomy (PEG) tube insertion is commonplace in head and neck cancer (HNC) patients. A rare but serious complication of PEG insertion in HNC is PEG site metastasis (PSM), which may precipitate rapid deterioration. We present the first case of PSM in a HNC patient managed without chemoradiotherapy and/or surgery, but rather with concurrent radiotherapy and cetuximab, followed by second-line pembrolizumab. Following histopathologic diagnosis of PSM, positron emission tomography confirmed primary site recurrence and multiple metastases in the axilla, abdomen and pelvis, managed palliatively with focal abdominal wall radiotherapy, pembrolizumab and carboplatin. The patient deteriorated and passed away 20 months after initial HNC diagnosis, 5 months after confirmation of PSM. Patients and clinicians should be aware of PSM in HNC. Though a proven prevention strategy is yet to be confirmed, prompt PSM diagnosis spares the patient unnecessary antibiotics for presumed infection and suggests the possibility of intra-abdominal metastases.
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Affiliation(s)
- Asanka R Wijetunga
- Sydney Medical School, Northern Clinical School, St Leonards, NSW, Australia.
| | - Adrian Lee
- Sydney Medical School, Northern Clinical School, St Leonards, NSW, Australia; Department of Medical Oncology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Dasantha T Jayamanne
- Sydney Medical School, Northern Clinical School, St Leonards, NSW, Australia; Department of Radiation Oncology, Royal North Shore Hospital, St Leonards, NSW, Australia
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Wijetunga AR, Tsang VH, Giuffre B. The utility of cross-sectional imaging in the management of suspected scaphoid fractures. J Med Radiat Sci 2019; 66:30-37. [PMID: 30160062 PMCID: PMC6399186 DOI: 10.1002/jmrs.302] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/23/2018] [Accepted: 07/27/2018] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Scaphoid fractures are the commonest carpal bone fracture. If untreated they pose significant risk to patients, thus if a scaphoid fracture is suspected, patients are managed with immobilisation. Although scaphoid fractures may be difficult to diagnose on plain radiography, sometimes for months after injury, ongoing radiographic surveillance is preferred due to its low upfront cost. Patients in immobilising casts for long periods experience significant personal and social ramifications such as difficulty working and self-caring. This study examines whether cross-sectional imaging by computed tomography (CT) or magnetic resonance imaging (MRI) is quicker than serial X-ray surveillance at allowing a scaphoid fracture to be either excluded or confirmed. METHODS A retrospective record review was performed of the 1709 patients who presented to Royal North Shore Hospital in 2015 with wrist injuries, finding 104 patients clinically suspicious for a fractured scaphoid. RESULTS All patients were examined by X-ray during their initial hospital presentation, providing 33.7% of final diagnoses in 0.6 ± 1.7 days. However, if initial X-ray proved inconclusive, subsequent serial X-ray surveillance made a final diagnosis after a mean of 24.1 ± 17.2 days, with some being immobilised for up to 67 days before diagnosis. Cross-sectional imaging significantly reduced diagnosis time to 9.8 ± 5.8 days (P = 0.0016), with a maximum immobilisation time of 24 days. CONCLUSION Cross-sectional imaging allows for faster scaphoid fracture diagnosis than X-ray. We propose a protocol for scaphoid fracture diagnosis wherein patients undergo two episodes of X-ray separated by 7 days, followed by a single MRI if clinical suspicion remains, minimising unnecessary immobilisation.
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Affiliation(s)
| | - Venessa H. Tsang
- Department of EndocrinologyRoyal North Shore HospitalSydneyAustralia
- Sydney Medical School, University of SydneySydneyAustralia
| | - Bruno Giuffre
- Sydney Medical School, University of SydneySydneyAustralia
- Department of RadiologyRoyal North Shore HospitalSydneyAustralia
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