Clinical and pathological factors associated with survival in patients with pancreatic cancer who receive adjuvant therapy after neoadjuvant therapy: A retrospective multi-institutional analysis

BACKGROUND

Neoadjuvant therapy is being increasingly used for patients with pancreatic cancer. The role of adjuvant therapy in these patients is unclear. The purpose of this study was to identify clinical and pathologic characteristics that are associated with longer overall survival in patients with pancreatic cancer who receive adjuvant therapy after neoadjuvant therapy.

METHODS

This study was conducted using multi-institutional data. All patients underwent surgery after at least 1 cycle of neoadjuvant therapy for pancreatic cancer. Patients who died within 3 months after surgery and were known to have distant metastasis or macroscopic residual disease were excluded. Mann-Whitney U test, χ2 analysis, Kaplan-Meier plot, and univariate and multivariate Cox regression analysis were performed as statistical analyses.

RESULTS

In the present study, 529 patients with resected pancreatic cancer after neoadjuvant therapy were reviewed. For neoadjuvant therapy, 177 (33.5%) patients received neoadjuvant chemotherapy, and 352 (66.5%) patients received neoadjuvant chemoradiotherapy. The median duration of neoadjuvant therapy was 7.0 months (interquartile range, 5.0-8.7). Patients were followed for a median of 23.0 months after surgery. Adjuvant therapy was administered to 297 (56.1%) patients and was not associated with longer overall survival for the entire cohort (24 vs 22 months, P = .31). Interaction analysis showed that adjuvant therapy was associated with longer overall survival in patients who received less than 4 months neoadjuvant therapy (hazard ratio 0.40; 95% confidence interval 0.17-0.95; P = .03) or who had microscopic margin positive surgical resections (hazard ratio 0.56; 95% confidence interval 0.33-0.93; P = .03).

CONCLUSION

In this retrospective study, there was a survival benefit associated with adjuvant therapy for patients who received less than 4 months of neoadjuvant therapy or had microscopic positive margins.

Pancreatic acinar cell carcinoma: A multi-center series on clinical characteristics and treatment outcomes

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Background: Acinar cell carcinoma (ACC) is a very rare tumor of the exocrine pancreas, representing less than 1% of all pancreatic malignancies. The majority of data regarding ACC are limited to small case series. Methods: This is a retrospective study conducted at a large healthcare system from 1996-2019. Patients with pathologically confirmed ACC were included, and demographic data, tumor characteristics, and treatment outcomes were abstracted by chart review. Survival curves were obtained by using the Kaplan-Meier method and compared using the log-rank test. Results: Sixty-six patients with ACC were identified. The median patient age at diagnosis was 64, and 42% presented with metastatic disease. The majority presented with abdominal pain or pancreatitis (69%), and laboratory parameters did not correlate with tumor size, metastatic disease, or survival. Several somatic abnormalities were noted in tumors (BRCA2, TP53, and mismatch-repair genes). In patients with localized disease that underwent resection, the median time to develop metastatic lesions was 13 months. The median overall survival (OS) was 24.7 months from diagnosis, with a survival difference based on metastatic disease at diagnosis (median 15 vs 38 mos). Surgery conferred OS benefit in non-metastatic cases (p = 0.006) but not metastatic cases (p = 0.22), and chemotherapy provided OS benefit in metastatic disease (p < 0.01). Patients with metastatic ACC treated after 2010 utilized more platinum-based agents, and there was a OS benefit to FOLFOX or FOLFIRINOX chemotherapy compared to gemcitabine or capecitabine-based regimens (p = 0.006). Conclusions: Pancreatic ACC patients often present with advanced disease. Surgery confers survival benefit among patients presenting with localized disease. The use of FOLFOX or FOLFIRINOX chemotherapy regimens was associated with improved OS in metastatic patients. These data add to our knowledge in this rare malignancy, and improves understanding about the genomic underpinnings, prognosis and treatment for acinar cancers.

Cerebral Venous Thrombosis Associated with COVID-19

Despite the severity of coronavirus disease 2019 (COVID-19) being more frequently related to acute respiratory distress syndrome and acute cardiac and renal injuries, thromboembolic events have been increasingly reported. We report a unique series of young patients with COVID-19 presenting with cerebral venous system thrombosis. Three patients younger than 41 years of age with confirmed Severe Acute Respiratory Syndrome coronavirus 2 (SARS-Cov-2) infection had neurologic findings related to cerebral venous thrombosis. They were admitted during the short period of 10 days between March and April 2020 and were managed in an academic institution in a large city. One patient had thrombosis in both the superficial and deep systems; another had involvement of the straight sinus, vein of Galen, and internal cerebral veins; and a third patient had thrombosis of the deep medullary veins. Two patients presented with hemorrhagic venous infarcts. The median time from COVID-19 symptoms to a thrombotic event was 7 days (range, 2-7 days). One patient was diagnosed with new-onset diabetic ketoacidosis, and another one used oral contraceptive pills. Two patients were managed with both hydroxychloroquine and azithromycin; one was treated with lopinavir-ritonavir. All patients had a fatal outcome. Severe and potentially fatal deep cerebral thrombosis may complicate the initial clinical presentation of COVID-19. We urge awareness of this atypical manifestation.

Microscopic size measurements in post-neoadjuvant therapy resections of pancreatic ductal adenocarcinoma (PDAC) predict patient outcomes

AIMS

Pancreatic ductal adenocarcinomas (PDACs) are increasingly being treated with neoadjuvant therapy. However, the American Joint Committee on Cancer (AJCC) 8th edition T staging based on tumour size does not reflect treatment effect, which often results in multiple, small foci of residual tumour in a background of mass-forming fibrosis. Thus, we evaluated the performance of AJCC 8th edition T staging in predicting patient outcomes by the use of a microscopic tumour size measurement method.

METHODS AND RESULTS

One hundred and six post-neoadjuvant therapy pancreatectomies were reviewed, and all individual tumour foci were measured. T stages based on gross size with microscopic adjustment (GS) and the largest single microscopic focus size (MFS) were examined in association with clinicopathological variables and patient outcomes. Sixty-three of 106 (59%) were locally advanced; 78% received FOLFIRINOX treatment. The average GS and MFS were 25 mm and 11 mm, respectively; nine cases each were classified as T0, 35 and 85 cases as T1, 42 and 12 cases as T2, and 20 and 0 cases as T3, based on the GS and the MFS, respectively. Higher GS-based and MFS-based T stages were significantly associated with higher tumour regression grade, lymphovascular and perineural invasion, and higher N stage. Furthermore, higher MFS-based T stage was significantly associated with shorter disease-free survival (DFS) (P < 0.001) and shorter overall survival (OS) (P = 0.002). GS was significantly associated with OS (P = 0.046), but not with DFS.

CONCLUSIONS

In post-neoadjuvant therapy PDAC resections, MFS-based T staging is superior to GS-based T staging for predicting patient outcomes, suggesting that microscopic measurements have clinical utility beyond the conventional use of GS measurements alone.

"Yes, I'm the Doctor": One Department's Approach to Assessing and Addressing Gender-Based Discrimination in the Modern Medical Training Era

While gender-based bias and discrimination (GBD) is known to exist in medical training, there is limited guidance for training programs on how to understand and combat this issue locally. The Massachusetts General Hospital Department of Surgery established the Gender Equity Task Force (GETF) to address GBD in the local training environment. In 2017, members of the GETF surveyed residents in surgery, anesthesia, and internal medicine at 2 academic hospitals to better understand perceived sources, frequency, forms, and effects of GBD. Overall, 371 residents completed the survey (60% response rate, 197 women). Women trainees were more likely to endorse personal experience of GBD and sexual harassment than men (P < .0001), with no effect of specialty on rates of GBD or sexual harassment. Patients and nursing staff were the most frequently identified groups as sources of GBD. While an overwhelming majority of both men (86%) and women (96%) respondents either experienced or observed GBD in the training environment, less than 5% of respondents formally reported such experiences, most frequently citing a belief that nothing would happen. Survey results served as the basis for a variety of interventions addressing nursing staff and patients as sources of GBD, low confidence in formal reporting mechanisms, and the pervasiveness of GBD, including sexual harassment, across specialties. These results reproduce other studies' findings that GBD and sexual harassment disproportionately affect women trainees while demonstrating how individual training programs can incorporate local GBD data when planning interventions to address GBD.

The effect of gender on operative autonomy in general surgery residents

BACKGROUND

Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees.

METHODS

A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis.

RESULTS

A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training.

CONCLUSION

There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents' experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.

Abstract 957: Use of angiotensin system inhibitors is associated with longer overall survival in pancreatic ductal adenocarcinoma patients who underwent pancreatectomy

Introduction: Angiotensin system inhibitors (ASI) are widely used to manage hypertension. Laboratory and retrospective clinical data suggests that ASIs can improve cancer prognosis. The aim of this study is to investigate the effect of ASIs on overall survival in pancreatic ductal adenocarcinoma (PDAC) patients.

Methods: We performed a retrospective review of the clinicopathologic records of patients with PDAC seen at the Massachusetts General Hospital (MGH) between 1/2006 - 12/2010. Patients on angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) were included as ASI users. We performed RNAseq and Gene Set Enrichment Analysis (GSEA) of primary tumor samples from patients with or without chronic ASI use. We also identified a surrogate signature of differentially expressed genes and we measured the extent of angiotensin inhibition in GEO and TCGA datasets. The extent of inhibition was used to correlate with survival. Statistical analysis was performed using Kaplan-Meier estimator and Cox proportional hazards ratio model.

Results: A total of 794 consecutive PDAC patients were included, of whom 297 (37.4%) were on ASIs and 183 (23.0%) were on non-ASI antihypertensive drug therapy. In resected patients, ASI users had a significantly longer overall survival on univariate (median OS: 36.3 vs. 19.3 months, p=0.011) and multivariate analysis (HR, 0.49; 95%CI, 0.333-0.734; p&lt;0.001). In our sub-group analysis of resected hypertensive patients treated with chemotherapy, chronic ASI users had a significantly longer overall survival than ASI-naïve patients (p=0.048) (28.7 vs 12.3 months, p&lt; 0.05). Gene Set Enrichment Analysis revealed that the ASI lisinopril down-regulated genes which stimulate the mitotic cell cycle, WNT and Notch signaling and the interaction between integrins and the extracellular matrix. Lisinopril also enhanced gene sets linked with oxidative phosphorylation, antigen processing and presentation and the cytotoxic activity of T cells. In unresected patients, the effect of ASI was only significant in patients with locally advanced disease in multivariate analysis (HR, 0.572; 95%CI, 0.386-0.847; p=0.005), but not in metastatic patients. The low expression of genes down-regulated by ACEi was also significantly associated with longer survival in the TCGA and GSE71729 datasets.

Conclusion: In patients with PDAC, ASI use is associated with longer overall survival in resected patients and may benefit patients with locally advanced disease. These findings suggest the need for a prospective study to determine the efficacy of ASI in PDAC patients.

Citation Format: Hao Liu, Matthias Pinter, Joao Incio, Hang Lee, William Ho, Jonathan Crain, Kamila Naxerova, Mengyang Di, Alex Jacobson, Daniella Dias Santos, Andrea Zanconato, Vikram Deshpande, Keith Lillemoe, Carlos Fernandez del Castillos, Michael Downes, Ronald Evans, James Michaelson, Cristina Ferrone, Yves Boucher, Jain K. Rakesh. Use of angiotensin system inhibitors is associated with longer overall survival in pancreatic ductal adenocarcinoma patients who underwent pancreatectomy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 957. doi:10.1158/1538-7445.AM2017-957

Variability in immune infiltrates and HLA expression in cholangiocarcinoma

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Background: Cholangiocarcinoma continues to have a dismal prognosis. The lack of effective therapy prompted us to determine whether patients develop an immune response against their own tumors. The aim of this study is to evaluate the CD8 infiltrate and expression of HLA class I antigen processing machinery (APM) components in cholangiocarcinoma. The HLA class I antigen processing machinery (APM) components play a crucial role in expression of HLA class I tumor antigen derived peptide complexes. These complexes mediate the recognition of tumor cells by cognate T cells. Defects in the expression of HLA class I APM components by tumor cells suggests that the infiltrating lymphocytes impose selective pressure on tumor cells. This selective pressure would facilitate the outgrowth of tumors by escaping T cell recognition. Methods: Retrospective review of clinicopathologic factors was performed for 18 peripheral cholangiocarcinomas. Formalin fixed, paraffin embedded tumors were evaluated for the content of lymphocyte infiltrates and for the expression of HLA class I APM components. Results: Eighteen patients underwent a partial hepatectomy for peripheral cholangiocarcinoma of whom 10 were female. Median age was 63yo. The majority of patients had node negative tumors (10/12). All tumors had lymphocytic infiltration. Median number of lymphocytes in the fibrous septae between tumor lobules was 42 CD8 T cells per 10 high power field, but only 4 CD8 T cells within tumor lobules. HLA class I APM components was defective and not detected in three tumors, all of which were poorly differentiated. HLA expression was down regulated in 9 tumors. HLA expression was in normal range in the remaining 6 tumors. Median overall survival has not been reached. Conclusions: Lymphocytic infiltrates were seen in all resected cholangiocarcinoma specimens. The loss of HLA class I APM component expression in cholangiocarcinoma suggests that infiltrating lymphocytes reflect a patient’s immune response to his/her tumor. This information provides a sound rationale to consider immunotherapy in the treatment of cholangiocarcinoma, specifically with antibodies to check point molecules which enhance patients’ immune response against his own tumors.

Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection

INTRODUCTION

Although Seprafilm has been demonstrated to reduce adhesion formation, it is not known whether its usage would translate into a reduction in adhesive small-bowel obstruction.

METHODS

This was a prospective, randomized, multicenter, multinational, single-blind, controlled study. This report focuses on those patients who underwent intestinal resection (n = 1,701). Before closure of the abdomen, patients were randomized to receive Seprafilm or no treatment. Seprafilm was applied to adhesiogenic tissues throughout the abdomen. The incidence and type of bowel obstruction was compared between the two groups. Time to first adhesive small-bowel obstruction was compared during the course of the study by using survival analysis methods. The mean follow-up time for the occurrence of adhesive small-bowel obstruction was 3.5 years.

RESULTS

There was no difference between the treatment and control group in overall rate of bowel obstruction. The incidence of adhesive small-bowel obstruction requiring reoperation was significantly lower for Seprafilm patients compared with no-treatment patients: 1.8 vs. 3.4 percent (P < 0.05). This finding represents an absolute reduction in adhesive small-bowel obstruction requiring reoperation of 1.6 percent and a relative reduction of 47 percent. In addition, a stepwise multivariate analysis indicated that the use of Seprafilm was the only predictive factor for reducing adhesive small-bowel obstruction requiring reoperation. In both groups, 50 percent of first adhesive small-bowel obstruction episodes occurred within 6 months after the initial surgery with nearly 30 percent occurring within the first 30 days. Additionally no first adhesive small-bowel obstruction events were reported in Years 4 and 5 of follow-up.

CONCLUSIONS

The overall bowel obstruction rate was unchanged; however, adhesive small-bowel obstruction requiring reoperation was significantly reduced by the use of Seprafilm, which was the only factor that predicted this outcome.

The effects of alcohol celiac plexus block, pain, and mood on longevity in patients with unresectable pancreatic cancer: a double-blind, randomized, placebo-controlled study

OBJECTIVE

This additional analysis of data from a previously reported prospective trial comparing the effect of intraoperative alcohol or saline placebo neurolytic block in patients with pancreatic cancer was conducted in response to the development of a new theory, which explores the relationship of negative mood states to pain, pain-related behavior, and ultimately, longevity.

METHODS

The original study used a double-blind procedure to randomly assign 139 patients with histologically proven, unresectable pancreatic cancer to receive either an alcohol or a saline block. Data on visual analog pain, mood, and interference with activity were collected preoperatively and every 2 months postoperatively until death. The current analysis was conducted on the complete data sets received from 130 patients. Demographic data were submitted to chi-square analysis and to univariate and multivariate analysis of variance. Univariate and multivariate analyses of variance also compared 1) the effect of alcohol versus saline on pain, mood, interference of pain with activities, and longevity and 2) the impact of mood on pain with longevity as the dependent variable. Correlation and regression analyses examined the impact of mood on life expectancy.

RESULTS

The alcohol intervention had a significant positive effect on life duration and mood scores. High negative mood states correlated significantly with an increase in visual analog pain, the rating of pain intensity at its worse, and pain interference with patients' activities.

CONCLUSION

In these subjects, the neurolytic block, as compared with medical management alone, improved pain, elevated mood, reduced pain interference with activity, and was associated with an increase in life expectancy.

Common bile duct complications of pancreatitis evaluation and treatment

Five cases that illustrate the spectrum of biliary complications of pancreatitis and pancreatic pseudocyst are discussed. Obstructive jaundice, hemobilia, and bilious ascites were the major problems in these five patients. Sonography, transhepatic cholangiogram, endoscopic retrograde cholangiopancreatography, operative cholangiography, and arteriography are important in establishing the diagnosis and planning the treatment. Three patients had biliary obstruction caused by chronic pancreatitis, a pancreatic pseudocyst, or both. Two patients had a fistula between the common duct and the pseudocyst. Simple decompression of the pseudocyst was curative for only one patient. Three patients required decompression of the biliary tract, which emphasizes the need for intraoperative cholangiography. One patient required a Whipple operation to control hemorrhage but died in the immediate postoperative period. The operative findings determine the specific procedures for biliary tract decompression and pseudocyst drainage.

Malignant neoplasms of the duodenum

The records of 17 patients with primary malignant neoplasms of the duodenum were reviewed. Fiberoptic endoscopy is a valuable method for preoperative diagnosis. The results are consistent with previous reports, in that surgical resection is the only satisfactory treatment for most malignant tumors of the duodenum. Segmental resection may be the preferred procedure for localized tumors as it is associated with a much lower operative mortality than is pancreaticoduodenectomy. Radiation therapy, however, is often effective in patients with lymphomas of the duodenum.