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Giaccherini M, Rende M, Gentiluomo M, Corradi C, Archibugi L, Ermini S, Maiello E, Morelli L, van Eijck CHJ, Cavestro GM, Schneider M, Mickevicius A, Adamonis K, Basso D, Hlavac V, Gioffreda D, Talar-Wojnarowska R, Schöttker B, Lovecek M, Vanella G, Gazouli M, Uno M, Malecka-Wojciesko E, Vodicka P, Goetz M, Bijlsma MF, Petrone MC, Bazzocchi F, Kiudelis M, Szentesi A, Carrara S, Nappo G, Brenner H, Milanetto AC, Soucek P, Katzke V, Peduzzi G, Rizzato C, Pasquali C, Chen X, Capurso G, Hackert T, Bueno-de-Mesquita B, Uzunoglu FGG, Hegyi P, Greenhalf W, Theodoropoulos GEE, Sperti C, Perri F, Oliverius M, Mambrini A, Tavano F, Farinella R, Arcidiacono PG, Lucchesi M, Bunduc S, Kupcinskas J, Di Franco G, Stocker S, Neoptolemos JP, Bambi F, Jamroziak K, Testoni SGG, Aoki MN, Mohelnikova-Duchonova B, Izbicki JR, Pezzilli R, Lawlor RT, Kauffmann EF, López de Maturana E, Malats N, Canzian F, Campa D. A pleiotropy scan to discover new susceptibility loci for pancreatic ductal adenocarcinoma. Mutagenesis 2024:geae012. [PMID: 38606763 DOI: 10.1093/mutage/geae012] [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: 01/25/2024] [Indexed: 04/13/2024] Open
Abstract
Pleiotropic variants (i.e., genetic polymorphisms influencing more than one phenotype) are often associated with cancer risk. A scan of pleiotropic variants was successfully conducted ten years ago in relation to pancreatic ductal adenocarcinoma susceptibility. However, in the last decade, genetic association studies performed on several human traits have greatly increased the number of known pleiotropic variants. Based on the hypothesis that variants already associated with a least one trait have a higher probability of association with other traits, 61,052 variants reported to be associated by at least one genome wide association study (GWAS) with at least one human trait were tested in the present study consisting of two phases (discovery and validation), comprising a total of 16,055 pancreatic ductal adenocarcinoma (PDAC) cases and 212,149 controls. The meta-analysis of the two phases showed two loci (10q21.1-rs4948550 (P=6.52×10-5) and 7q36.3-rs288762 (P=3.03×10-5) potentially associated with PDAC risk. 10q21.1-rs4948550 shows a high degree of pleiotropy and it is also associated with colorectal cancer risk while 7q36.3-rs288762 is situated 28,558 base pairs upstream of the Sonic Hedgehog (SHH) gene, which is involved in the cell differentiation process and PDAC etiopathogenesis. In conclusion, none of the single nucleotide polymorphisms (SNPs) showed a formally statistically significant association after correction for multiple testing. However, given their pleiotropic nature and association with various human traits including colorectal cancer, the two SNPs showing the best associations with PDAC risk merit further investigation through fine mapping and ad hoc functional studies.
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Affiliation(s)
- M Giaccherini
- Department of Biology, University of Pisa, Pisa, Italy
| | - M Rende
- Department of Biology, University of Pisa, Pisa, Italy
| | - M Gentiluomo
- Department of Biology, University of Pisa, Pisa, Italy
| | - C Corradi
- Department of Biology, University of Pisa, Pisa, Italy
| | - L Archibugi
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Rome, Italy
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRSSC San Raffaele Scientific Institute, Milan, Italy
| | - S Ermini
- Blood Transfusion Service, Azienda Ospedaliero Universitaria Meyer, Florence, Italy
| | - E Maiello
- Department of Oncology, Fondazione IRCCS "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Italy
| | - L Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - C H J van Eijck
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - G M Cavestro
- Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele, Milan, Italy
| | - M Schneider
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - A Mickevicius
- Surgery Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - K Adamonis
- Gastroenterology Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - D Basso
- Department of Surgery, Oncology and Gastroenterology-DiSCOG, University of Padova, Padua, Italy
| | - V Hlavac
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - D Gioffreda
- Division of Gastroenterology and Research Laboratory, Fondazione IRCCS "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Italy
| | - R Talar-Wojnarowska
- Department of Digestive Tract Diseases, Medical University of Lodz, Lodz, Poland
| | - B Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
| | - M Lovecek
- Department of Surgery I, University Hospital Olomouc, Olomouc, Czech Republic
| | - G Vanella
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Rome, Italy
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRSSC San Raffaele Scientific Institute, Milan, Italy
| | - M Gazouli
- Department of Basic Medical Sciences, Laboratory of Biology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - M Uno
- Center for Translational Research in Oncology (LIM24), Instituto Do Câncer Do Estado de São Paulo, (ICESP), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, Brazil
| | - E Malecka-Wojciesko
- Department of Digestive Tract Diseases, Medical University of Lodz, Lodz, Poland
| | - P Vodicka
- Institute of Experimental Medicine, Czech Academy of Science, Prague, Czech Republic
- Institute of Biology and Medical Genetics, 1st Medical Faculty, Charles University in Prague, Prague, Czech Republic
| | - M Goetz
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M F Bijlsma
- Laboratory for Experimental Oncology and Radiobiology, Center for Experimental and Molecular Medicine, Amsterdam UMC and Cancer Center Amsterdam, Amsterdam, The Netherlands
- Oncode Institute, Amsterdam, The Netherlands
| | - M C Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRSSC San Raffaele Scientific Institute, Milan, Italy
| | - F Bazzocchi
- Department of Surgery, Fondazione IRCCS "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Italy
| | - M Kiudelis
- Surgery Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - A Szentesi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Department of Medicine, University of Szeged, Szeged, Hungary
| | - S Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center IRCCS, Milan, Italy
| | - G Nappo
- Pancreatic Unit, Humanitas Clinical and Research Center IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - H Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - A C Milanetto
- Department of Surgery, Oncology and Gastroenterology-DiSCOG, University of Padova, Padua, Italy
| | - P Soucek
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - V Katzke
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - G Peduzzi
- Department of Biology, University of Pisa, Pisa, Italy
| | - C Rizzato
- Department of Biology, University of Pisa, Pisa, Italy
| | - C Pasquali
- Department of Surgery, Oncology and Gastroenterology-DiSCOG, University of Padova, Padua, Italy
| | - X Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
| | - G Capurso
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Rome, Italy
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRSSC San Raffaele Scientific Institute, Milan, Italy
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - B Bueno-de-Mesquita
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - F G G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - P Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - W Greenhalf
- Institute for Health Research Liverpool Pancreas Biomedical Research Unit, University of Liverpool, Liverpool, United Kingdom
| | - G E E Theodoropoulos
- First Department of Propaedeutic Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - C Sperti
- Department of Surgery, Oncology and Gastroenterology-DiSCOG, University of Padova, Padua, Italy
| | - F Perri
- Division of Gastroenterology and Research Laboratory, Fondazione IRCCS "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Italy
| | - M Oliverius
- Surgery Clinic Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - A Mambrini
- Oncological Department Massa Carrara, Azienda USL Toscana Nord Ovest, Carrara, Italy
| | - F Tavano
- Division of Gastroenterology and Research Laboratory, Fondazione IRCCS "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Italy
| | - R Farinella
- Department of Biology, University of Pisa, Pisa, Italy
| | - P G Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRSSC San Raffaele Scientific Institute, Milan, Italy
| | - M Lucchesi
- Oncological Department Massa Carrara, Azienda USL Toscana Nord Ovest, Carrara, Italy
| | - S Bunduc
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - J Kupcinskas
- Gastroenterology Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - G Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - S Stocker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
| | - J P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - F Bambi
- Blood Transfusion Service, Azienda Ospedaliero Universitaria Meyer, Florence, Italy
| | - K Jamroziak
- Department of Hematology, Transplantology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - S G G Testoni
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRSSC San Raffaele Scientific Institute, Milan, Italy
| | - M N Aoki
- Laboratory for Applied Science and Technology in Health, Carlos Chagas Institute, Oswaldo Cruz Foundation (Fiocruz), Curitiba, Brazil
| | | | - J R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - R Pezzilli
- County Medical Association of Potenza, Potenza, Italy
| | - R T Lawlor
- ARC-NET: Centre for Applied Research on Cancer, University and Hospital Trust of Verona, Verona, Italy
| | - E F Kauffmann
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - E López de Maturana
- Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
| | - N Malats
- Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
| | - F Canzian
- Genomic Epidemiology Group, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - D Campa
- Department of Biology, University of Pisa, Pisa, Italy
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Büchler MW, Neoptolemos JP. The NEONAX study. Ann Oncol 2023; 34:442-443. [PMID: 36681300 DOI: 10.1016/j.annonc.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023] Open
Affiliation(s)
- M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Baden-Württemberg, Germany
| | - J P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Baden-Württemberg, Germany.
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Neoptolemos JP, Greenhalf W. Linking COVID-19 and Acute Pancreatitis Through the Pathogenic Effects of the SARS-CoV-2 S Protein Subunit 1 on Pancreatic Stellate Cells and Macrophages. Function (Oxf) 2022; 3:zqac009. [PMID: 35399494 PMCID: PMC8903514 DOI: 10.1093/function/zqac009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 02/20/2022] [Indexed: 01/07/2023]
Affiliation(s)
| | - W Greenhalf
- Liverpool GCPLab Facility, University of Liverpool, Liverpool, L7 8TX, UK
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Xu D, Zhang K, Li M, Neoptolemos JP, Wu J, Gao W, Wu P, Cai B, Yin J, Shi G, Lu Z, Jiang K, Miao Y. Prognostic Nomogram for Resected Pancreatic Adenocarcinoma: A TRIPOD-Compliant Retrospective Long-Term Survival Analysis. World J Surg 2020; 44:1260-1269. [PMID: 31900571 DOI: 10.1007/s00268-019-05325-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prognostic prediction had been widely used in various cancer entities, from early screening to end-stage patient caring. Currently, there is hardly any well-validated nomogram which exists for long-term survival prediction in pancreatic adenocarcinoma (PC) patients in a post-surgery setting. Our objectives are to identify possible prognostic factors in PC patients following radical resection and to develop a prognostic nomogram based on independent survival predictors. METHODS From 2009 to 2014, a total of 432 PC patients who underwent curative intended surgeries with complete follow-up data were included in this current retrospective long-term survival analysis. Clinicopathological data were extracted from medical records, and all missing values (percentage 0.9-8.3%) were imputed five times with the "PMM" method. Cox proportional hazards models were utilized. A nomogram was formulated based on results from the multivariate regression model so as to predict OS at 1-, 2- and 3-year as well as median OS. Validations, including discrimination and calibration, were carried out with 1000 bootstrap resamples. External validation was conducted in order to verify the accuracy of our nomogram at 1 and 2 years by utilizing the clinicopathological data of 122 PC patients who underwent curative intended surgeries in 2015 in our centre. RESULTS Age, abdominal pain, back pain, tumour location, preoperative neutrophil-lymphocyte ratio, preoperative CA19-9, tumour differentiation, microscopic nerve invasion, microscopic vascular invasion, T stage, lymph node ratio, M stage and adjuvant chemotherapy were all assembled into nomogram. The concordance index (C-index) of internal and external validation was 0.702 and 0.688, respectively. The C-index of the TNM staging system was 0.572 (P < 0.001 vs. nomogram). CONCLUSION Our prognostic nomogram based on clinicopathological parameters shows good performance in long-term survival prediction in PC patients following radical surgery and could play a role in further clinical utilization.
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Affiliation(s)
- Dong Xu
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Kai Zhang
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Mingna Li
- Pathology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - J P Neoptolemos
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.,Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Junli Wu
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Wentao Gao
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Pengfei Wu
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Baobao Cai
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Jie Yin
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Guodong Shi
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Zipeng Lu
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
| | - Kuirong Jiang
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
| | - Yi Miao
- Pancreas Center and Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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Springfeld C, Hackert T, Jäger D, Büchler MW, Neoptolemos JP. Neoadjuvante und adjuvante Therapie beim Pankreaskarzinom. Chirurg 2020; 91:636-641. [DOI: 10.1007/s00104-020-01169-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sheel ARG, Baron RD, Dickerson LD, Ghaneh P, Campbell F, Raraty MGT, Yip V, Halloran CM, Neoptolemos JP. The Liverpool duodenum-and spleen-preserving near-total pancreatectomy can provide long-term pain relief in patients with end-stage chronic pancreatitis. Langenbecks Arch Surg 2019; 404:831-840. [PMID: 31748872 DOI: 10.1007/s00423-019-01837-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Total pancreatectomy may improve symptoms in patients with severe end-stage chronic pancreatitis. This might be achieved whilst preserving both the duodenum- and spleen-(DPSPTP). Mature clinical outcomes of this approach are presented. METHODS Single-centre prospective cohort study performed between September 1996 and May 2016. Demographic, clinical details, pain scores and employment status were prospectively recorded during clinic attendance. RESULTS Fifty-one patients (33 men, 18 women) with a median (interquartile range) age of 40.8 (35.3-49.4) years, a median weight of 69.8 (61.0-81.5) Kg and a median body mass index of 23.8 (21.5-27.8), underwent intended duodenum-and spleen-preserving near-total pancreatectomy for end-stage chronic pancreatitis. Aetiology was excess alcohol in 25, idiopathic (no mutation) in 15, idiopathic (SPINK-1/CFTR mutations) in two, hereditary (PRSS1 mutation) in seven and one each post-necrotising pancreatitis and obstructive pancreatic duct divisum in 1. The main indication for surgery was severe pain. Findings included parenchymal calcification in 79% and ductal calculi in 24%, a dilated main pancreatic duct in 57% and a dilated main bile duct in 17%, major vascular involvement in 27% and pancreato-peritoneal fistula in 2%. Postoperative complications occurred in 20 patients with two deaths. Median pain scores were 8 (7-8) preoperatively and 3 (0.25-5.75) at 5 years (p = 0.013). Opiate analgesic use was significantly reduced postoperatively (p = 0.048). Following surgery, 22 (63%) of 38 patients of working age re-entered employment compared with 12 (33%) working preoperatively (p = 0.016). CONCLUSION Duodenum-and spleen-preserving near-total pancreatectomy provided long-term relief in adult patients with intractable chronic pancreatitis pain, with improved employment prospects.
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Affiliation(s)
- A R G Sheel
- Department of Clinical Cancer Medicine, Institute of Translational Medicine, The University of Liverpool, Liverpool, UK
- Department of Pancreato-Biliary Surgery, The Royal Liverpool University Hospital, Liverpool, UK
| | - R D Baron
- Department of Clinical Cancer Medicine, Institute of Translational Medicine, The University of Liverpool, Liverpool, UK
- Department of Pancreato-Biliary Surgery, The Royal Liverpool University Hospital, Liverpool, UK
| | - L D Dickerson
- Department of Pancreato-Biliary Surgery, The Royal Liverpool University Hospital, Liverpool, UK
| | - P Ghaneh
- Department of Clinical Cancer Medicine, Institute of Translational Medicine, The University of Liverpool, Liverpool, UK
- Department of Pancreato-Biliary Surgery, The Royal Liverpool University Hospital, Liverpool, UK
| | - F Campbell
- Department of Histopathology, The Royal Liverpool University Hospital, Liverpool, UK
| | - M G T Raraty
- Department of Pancreato-Biliary Surgery, The Royal Liverpool University Hospital, Liverpool, UK
| | - V Yip
- The Royal London Hospital, Whitechapel, London, UK
| | - C M Halloran
- Department of Clinical Cancer Medicine, Institute of Translational Medicine, The University of Liverpool, Liverpool, UK
- Department of Pancreato-Biliary Surgery, The Royal Liverpool University Hospital, Liverpool, UK
| | - J P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Baden-Württemberg, Germany.
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Dickerson LD, Farooq A, Bano F, Kleeff J, Baron R, Raraty M, Ghaneh P, Sutton R, Whelan P, Campbell F, Healey P, Neoptolemos JP, Yip VS. Differentiation of Autoimmune Pancreatitis from Pancreatic Cancer Remains Challenging. World J Surg 2019; 43:1604-1611. [PMID: 30815742 DOI: 10.1007/s00268-019-04928-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis. Whilst being corticosteroid responsive, AIP often masquerades radiologically as pancreatic neoplasia. Our aim is to appraise demographic, radiological and histological features in our cohort in order to differentiate AIP from pancreatic malignancy. METHODS Clinical, biochemical, histological and radiological details of all AIP patients 1997-2016 were analysed. The initial imaging was re-reviewed according to international guidelines by three blinded independent radiologists to evaluate features associated with autoimmune pancreatitis and pancreatic cancer. RESULTS There were a total of 45 patients: 25 in type 1 (55.5%), 14 type 2 (31.1%) and 6 AIP otherwise not specified (13.3%). The median (IQR) age was 57 (51-70) years. Thirty patients (66.6%) were male. Twenty-six patients (57.8%) had resection for suspected malignancy and one for symptomatic chronic pancreatitis. Three had histologically proven malignancy with concurrent AIP. Two patients died from recurrent pancreatic cancer following resection. Multidisciplinary team review based on radiology and clinical history dictated management. Resected patients (vs. non-resected group) were older (64 vs. 53, p = 0.003) and more frequently had co-existing autoimmune pathologies (22.2 vs. 55.6%, p = 0.022). Resected patients also presented with less classical radiological features of AIP, which are halo sign (0/25 vs. 3/17, p = 0.029) and loss of pancreatic clefts (18/25 vs. 17/17, p = 0.017). There were no differences in demographic features other than age. CONCLUSION Despite international guidelines for diagnosing AIP, differentiation from pancreatic cancer remains challenging. Resection remains an important treatment option in suspected cancer or where conservative treatment fails.
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Affiliation(s)
- L D Dickerson
- Pancreas Unit, Department of General Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - A Farooq
- Department of Radiology, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - F Bano
- Department of Radiology, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - J Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, 06120, Halle (Saale), Germany
| | - R Baron
- Pancreas Unit, Department of General Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - M Raraty
- Pancreas Unit, Department of General Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - P Ghaneh
- Pancreas Unit, Department of General Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - R Sutton
- Pancreas Unit, Department of General Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - P Whelan
- Pancreas Unit, Department of General Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - F Campbell
- Department of Pathology, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - P Healey
- Department of Radiology, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
| | - J P Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - V S Yip
- Pancreas Unit, Department of General Surgery, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK.
- Department of Hepatobiliary and Pancreas Surgery, 13C Royal London Hospital, Whitechapel Road, London, E1 1BB, UK.
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Elander NO, Aughton K, Ghaneh P, Neoptolemos JP, Palmer DH, Cox TF, Campbell F, Costello E, Halloran CM, Mackey JR, Scarfe AG, Valle JW, McDonald AC, Carter R, Tebbutt NC, Goldstein D, Shannon J, Dervenis C, Glimelius B, Deakin M, Charnley RM, Anthoney A, Lerch MM, Mayerle J, Oláh A, Büchler MW, Greenhalf W. Intratumoural expression of deoxycytidylate deaminase or ribonuceotide reductase subunit M1 expression are not related to survival in patients with resected pancreatic cancer given adjuvant chemotherapy. Br J Cancer 2018; 118:1084-1088. [PMID: 29523831 PMCID: PMC5931097 DOI: 10.1038/s41416-018-0005-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/04/2018] [Accepted: 01/04/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Deoxycytidylate deaminase (DCTD) and ribonucleotide reductase subunit M1 (RRM1) are potential prognostic and predictive biomarkers for pyrimidine-based chemotherapy in pancreatic adenocarcinoma. METHODS Immunohistochemical staining of DCTD and RRM1 was performed on tissue microarrays representing tumour samples from 303 patients in European Study Group for Pancreatic Cancer (ESPAC)-randomised adjuvant trials following pancreatic resection, 272 of whom had received gemcitabine or 5-fluorouracil with folinic acid in ESPAC-3(v2), and 31 patients from the combined ESPAC-3(v1) and ESPAC-1 post-operative pure observational groups. RESULTS Neither log-rank testing on dichotomised strata or Cox proportional hazard regression showed any relationship of DCTD or RRM1 expression levels to survival overall or by treatment group. CONCLUSIONS Expression of either DCTD or RRM1 was not prognostic or predictive in patients with pancreatic adenocarcinoma who had had post-operative chemotherapy with either gemcitabine or 5-fluorouracil with folinic acid.
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Affiliation(s)
- N O Elander
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - K Aughton
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - P Ghaneh
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - J P Neoptolemos
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - D H Palmer
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - T F Cox
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - F Campbell
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - E Costello
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - C M Halloran
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - J R Mackey
- Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - A G Scarfe
- Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - J W Valle
- University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
| | - A C McDonald
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - R Carter
- Glasgow Royal Infirmary, Glasgow, UK
| | | | - D Goldstein
- Prince of Wales hospital and Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - J Shannon
- Nepean Cancer Centre and University of Sydney, Camperdown, NSW, Australia
| | | | - B Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - M Deakin
- University Hospital, North Staffordshire, Staffordshire, UK
| | | | - A Anthoney
- St James's University Hospital, Leeds, UK
| | - M M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - J Mayerle
- Department of Medicine II, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - A Oláh
- The Petz Aladar Hospital, Gyor, Hungary
| | - M W Büchler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - W Greenhalf
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK.
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9
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Elander NO, Aughton K, Ghaneh P, Neoptolemos JP, Palmer DH, Cox TF, Campbell F, Costello E, Halloran CM, Mackey JR, Scarfe AG, Valle JW, McDonald AC, Carter R, Tebbutt NC, Goldstein D, Shannon J, Dervenis C, Glimelius B, Deakin M, Charnley RM, Anthoney A, Lerch MM, Mayerle J, Oláh A, Büchler MW, Greenhalf W. Expression of dihydropyrimidine dehydrogenase (DPD) and hENT1 predicts survival in pancreatic cancer. Br J Cancer 2018; 118:947-954. [PMID: 29515256 PMCID: PMC5931115 DOI: 10.1038/s41416-018-0004-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/21/2017] [Accepted: 01/04/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Dihydropyrimidine dehydrogenase (DPD) tumour expression may provide added value to human equilibrative nucleoside transporter-1 (hENT1) tumour expression in predicting survival following pyrimidine-based adjuvant chemotherapy. METHODS DPD and hENT1 immunohistochemistry and scoring was completed on tumour cores from 238 patients with pancreatic cancer in the ESPAC-3(v2) trial, randomised to either postoperative gemcitabine or 5-fluorouracil/folinic acid (5FU/FA). RESULTS DPD tumour expression was associated with reduced overall survival (hazard ratio, HR = 1.73 [95% confidence interval, CI = 1.21-2.49], p = 0.003). This was significant in the 5FU/FA arm (HR = 2.07 [95% CI = 1.22-3.53], p = 0.007), but not in the gemcitabine arm (HR = 1.47 [0.91-3.37], p = 0.119). High hENT1 tumour expression was associated with increased survival in gemcitabine treated (HR = 0.56 [0.38-0.82], p = 0.003) but not in 5FU/FA treated patients (HR = 1.19 [0.80-1.78], p = 0.390). In patients with low hENT1 tumour expression, high DPD tumour expression was associated with a worse median [95% CI] survival in the 5FU/FA arm (9.7 [5.3-30.4] vs 29.2 [19.5-41.9] months, p = 0.002) but not in the gemcitabine arm (14.0 [9.1-15.7] vs. 18.0 [7.6-15.3] months, p = 1.000). The interaction of treatment arm and DPD expression was not significant (p = 0.303), but the interaction of treatment arm and hENT1 expression was (p = 0.009). CONCLUSION DPD tumour expression was a negative prognostic biomarker. Together with tumour expression of hENT1, DPD tumour expression defined patient subgroups that might benefit from either postoperative 5FU/FA or gemcitabine.
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Affiliation(s)
- N O Elander
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - K Aughton
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - P Ghaneh
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - J P Neoptolemos
- The Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - D H Palmer
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - T F Cox
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - F Campbell
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - E Costello
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - C M Halloran
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - J R Mackey
- Cross Cancer Institute and University of Alberta, Alberta, Canada
| | - A G Scarfe
- Cross Cancer Institute and University of Alberta, Alberta, Canada
| | - J W Valle
- University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
| | - A C McDonald
- The Beatson West of Scotland Cancer Centre, Glasgow, Scotland, UK
| | - R Carter
- Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | | | - D Goldstein
- Prince of Wales hospital and Clinical School University of New South Wales, New South Wales, Australia
| | - J Shannon
- Nepean Cancer Centre and University of Sydney, Sydney, Australia
| | | | - B Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - M Deakin
- University Hospital, North Staffordshire, UK
| | | | | | - M M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - J Mayerle
- Department of Medicine II, University Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - A Oláh
- The Petz Aladar Hospital, Gyor, Hungary
| | - M W Büchler
- The Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - W Greenhalf
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK.
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10
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Bird NTE, Elmasry M, Jones R, Psarelli E, Dodd J, Malik H, Greenhalf W, Kitteringham N, Ghaneh P, Neoptolemos JP, Palmer D. Immunohistochemical hENT1 expression as a prognostic biomarker in patients with resected pancreatic ductal adenocarcinoma undergoing adjuvant gemcitabine-based chemotherapy. Br J Surg 2017; 104:328-336. [PMID: 28199010 DOI: 10.1002/bjs.10482] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/12/2016] [Accepted: 12/08/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Human equilibrative nucleoside transporters (hENTs) are transmembranous proteins that facilitate the uptake of nucleosides and nucleoside analogues, such as gemcitabine, into the cell. The abundance of hENT1 transporters in resected pancreatic ductal adenocarcinoma (PDAC) might make hENT1 a potential biomarker of response to adjuvant chemotherapy. The aim of this study was to see whether hENT1 expression, as determined by immunohistochemistry, was a suitable predictive marker for subsequent treatment with gemcitabine-based adjuvant chemotherapy. METHODS A systematic review was performed, searching databases from January 1997 to January 2016. Articles pertaining to hENT1 immunohistochemical analysis in resected PDAC specimens from patients who subsequently underwent adjuvant gemcitabine-based chemotherapy were identified. Eligible studies were required to contain survival data, reporting specifically overall survival (OS) and disease-free survival (DFS) with associated hazard ratios (HRs) stratified by hENT1 status. RESULTS Of 42 articles reviewed, eight were suitable for review, with seven selected for quantitative meta-analysis. The total number of patients included in the meta-analysis was 770 (405 hENT1-negative, 365 hENT1-positive). Immunohistochemically detected hENT1 expression was significantly associated with both prolonged DFS (HR 0·58, 95 per cent c.i. 0·42 to 0·79) and OS (HR 0·52, 0·38 to 0·72) in patients receiving adjuvant gemcitabine but not those having fluoropyrimidine-based adjuvant therapy. CONCLUSION Expression of hENT1 is a suitable prognostic biomarker in patients undergoing adjuvant gemcitabine-based chemotherapy.
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Affiliation(s)
- N T E Bird
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
| | - M Elmasry
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
| | - R Jones
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
| | - E Psarelli
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
| | - J Dodd
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
| | - H Malik
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
| | - W Greenhalf
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
| | - N Kitteringham
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
| | - P Ghaneh
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
| | - J P Neoptolemos
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
| | - D Palmer
- Liverpool University Pharmacology Unit, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK
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11
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Jenkinson C, Elliott V, Menon U, Apostolidou S, Fourkala OE, Gentry-Maharaj A, Pereira SP, Jacobs I, Cox TF, Greenhalf W, Timms JF, Sutton R, Neoptolemos JP, Costello E. Evaluation in pre-diagnosis samples discounts ICAM-1 and TIMP-1 as biomarkers for earlier diagnosis of pancreatic cancer. J Proteomics 2015; 113:400-2. [PMID: 25316052 DOI: 10.1016/j.jprot.2014.10.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/02/2014] [Indexed: 12/17/2022]
Abstract
Circulating intercellular adhesion molecule-1 (ICAM-1) and tissue inhibitor of metalloproteinases-1 (TIMP-1) have been widely proposed as potential diagnostic biomarkers for pancreatic ductal adenocarcinoma (PDAC). We report on serum protein levels prior to clinical presentation of pancreatic cancer. Serum ICAM-1 and TIMP-1 were measured by ELISA in two case–control sets: 1) samples from patients diagnosed with pancreatic cancer (n = 40), chronic pancreatitis (n = 20), benign jaundice due to gall stones (n = 20) and healthy subjects (n = 20); 2) a preclinical set from the UK Collaborative Trial of Ovarian Cancer Screening biobank of samples collected from 27 post-menopausal women 0–12 months prior to diagnosis of pancreatic cancer and controls matched for date of donation and centre. Levels of ICAM-1 and TIMP-1 were significantly elevated in set 1 in PDAC patients with jaundice compared to PDAC patients without jaundice and both proteins were elevated in patients with jaundice due to gall stones. Neither protein was elevated in samples taken 0–12 months prior to PDAC diagnosis compared to non-cancer control samples. In conclusion, evaluation in pre-diagnosis samples discounts ICAM-1 and TIMP-1 as biomarkers for earlier diagnosis of pancreatic cancer. Failure to account for obstructive jaundice may have contributed to the previous promise of these candidate biomarkers. BIOLOGICAL SIGNIFICANCE Pancreatic cancer is usually diagnosed when at an advanced stage which greatly limits therapeutic options. Biomarkers that could facilitate earlier diagnosis are urgently sought.
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12
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Shaw VE, Naisbitt DJ, Costello E, Greenhalf W, Park BK, Neoptolemos JP, Middleton GW. Current status of GV1001 and other telomerase vaccination strategies in the treatment of cancer. Expert Rev Vaccines 2014; 9:1007-16. [DOI: 10.1586/erv.10.92] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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13
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Tonack S, Jenkinson C, Cox T, Elliott V, Jenkins RE, Kitteringham NR, Greenhalf W, Shaw V, Michalski CW, Friess H, Neoptolemos JP, Costello E. iTRAQ reveals candidate pancreatic cancer serum biomarkers: influence of obstructive jaundice on their performance. Br J Cancer 2013; 108:1846-53. [PMID: 23579209 PMCID: PMC3658525 DOI: 10.1038/bjc.2013.150] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/09/2013] [Accepted: 03/14/2013] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The aims of our study were to identify serum biomarkers that distinguish pancreatic cancer (pancreatic ductal adenocarcinoma, PDAC) patients from benign pancreatic disease patients and healthy subjects, and to assess the effects of jaundice on biomarker performance. METHODS Isobaric tags for relative and absolute quantification were used to compare pooled serum and pancreatic juice samples from a test set of 59 and 25 subjects, respectively. Validation was undertaken in 113 independent subjects. RESULTS Candidate proteins Complement C5, inter-α-trypsin inhibitor heavy chain H3, α1-β glycoprotein and polymeric immunoglobulin receptor were elevated in cancer, as were the reference markers CA19-9 and Reg3A. Biliary obstruction had a significant effect on the performance of the markers, in particular within the PDAC group where the presence of jaundice was associated with a significant increase in the levels of all six proteins (P<0.01). Consequently, in the absence of jaundice, proteins showed reduced sensitivity for PDAC patients over benign subjects and healthy controls (HCs). Similarly, in the presence of jaundice, markers showed reduced specificity for PDAC patients over benign subjects with jaundice. Combining markers enabled improved sensitivity for non-jaundiced PDAC patients over HCs and improved specificity for jaundiced PDAC patients over jaundiced benign disease subjects. CONCLUSIONS The presence-absence of jaundice in the clinical scenario severely impacts the performance of biomarkers for PDAC diagnosis and has implications for their clinical translation.
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Affiliation(s)
- S Tonack
- Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK
| | - C Jenkinson
- Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK
| | - T Cox
- Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK
| | - V Elliott
- Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK
- National Institute for Health Research Liverpool Pancreatic Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - R E Jenkins
- Department of Pharmacology and Therapeutics, MRC Centre for Drug Safety Science, Liverpool, UK
| | - N R Kitteringham
- Department of Pharmacology and Therapeutics, MRC Centre for Drug Safety Science, Liverpool, UK
| | - W Greenhalf
- Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK
- National Institute for Health Research Liverpool Pancreatic Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - V Shaw
- Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK
| | - C W Michalski
- Department of General Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - H Friess
- Department of General Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - J P Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK
- National Institute for Health Research Liverpool Pancreatic Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - E Costello
- Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK
- National Institute for Health Research Liverpool Pancreatic Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
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14
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Van Laethem JL, Verslype C, Iovanna JL, Michl P, Conroy T, Louvet C, Hammel P, Mitry E, Ducreux M, Maraculla T, Uhl W, Van Tienhoven G, Bachet JB, Maréchal R, Hendlisz A, Bali M, Demetter P, Ulrich F, Aust D, Luttges J, Peeters M, Mauer M, Roth A, Neoptolemos JP, Lutz M. New strategies and designs in pancreatic cancer research: consensus guidelines report from a European expert panel. Ann Oncol 2012; 23:570-576. [PMID: 21810728 DOI: 10.1093/annonc/mdr351] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Although the treatment of pancreatic ductal adenocarcinoma (PDAC) remains a huge challenge, it is entering a new era with the development of new strategies and trial designs. Because there is an increasing number of novel therapeutic agents and potential combinations available to test in patients with PDAC, the identification of robust prognostic and predictive markers and of new targets and relevant pathways is a top priority as well as the design of adequate trials incorporating molecular-driven hypothesis. We presently report a consensus strategy for research in pancreatic cancer that was developed by a multidisciplinary panel of experts from different European institutions and collaborative groups involved in pancreatic cancer. The expert panel embraces the concept of exploratory early proof of concept studies, based on the prediction of response to novel agents and combinations, and randomised phase II studies permitting the selection of the best therapeutic approach to go forward into phase III, where the recommended primary end point remains overall survival. Trials should contain as many translational components as possible, relying on standardised tissue and blood processing and robust biobanking, and including dynamic imaging. Attention should not only be paid to the pancreatic cancer cells but also to microenvironmental factors and stem/stellate cells.
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Affiliation(s)
- J-L Van Laethem
- Gastrointestinal Cancer Unit, Hôpital Erasme, Université Libre de Bruxelles, Brussels.
| | - C Verslype
- Department of Hepatology, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium
| | - J L Iovanna
- Institut National de la Santé et de la Recherche Médicale, Marseille, France
| | - P Michl
- Department of Gastroenterology and Endocrinology, University of Marburg, Marburg, Germany
| | - T Conroy
- Nancy University and Department of Medical Oncology, Centre Alexis Vautrin, Nancy
| | - C Louvet
- Digestive Surgery Department, Institut Mutualiste Montsouris, Paris
| | - P Hammel
- Gastroenterology Department, Hôpital Beaujon, Clichy
| | - E Mitry
- Medical Oncology Department, Institut Curie, Hôpital René-Huguenin, Saint-Cloud
| | - M Ducreux
- Digestive Oncology Department, Institut G. Roussy, Villejuif, France
| | - T Maraculla
- Medical Oncology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - W Uhl
- Department of Surgery, St Josef-Hospital, Ruhr-University, Bochum, Germany
| | - G Van Tienhoven
- Department of Radiation Oncology, Academic Medical Centre, Amsterdam, The Netherlands
| | - J B Bachet
- Department of Gastroenterology, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - R Maréchal
- Department of Gastroenterology and Hepato-Pancreatology, Gastrointestinal Cancer Unit, Hôpital Universitaire Erasme, Brussels
| | - A Hendlisz
- Department of Gastroenterology, Institut J. Bordet, Brussels
| | - M Bali
- Department of Medical Imaging, Hôpital Erasme, Brussels, Belgium
| | - P Demetter
- Gastrointestinal Cancer Unit, Hôpital Erasme, Université Libre de Bruxelles, Brussels
| | - F Ulrich
- Department of General and Visceral Surgery, J. W. Goethe University Medical Center, Frankfurt
| | - D Aust
- Institute of Pathology, University Hospital Carl Gustav Carus, Dresden
| | - J Luttges
- Caritasklinik St Theresia, Saarbrücken, Germany
| | - M Peeters
- Department of Oncology, Universitair Ziekenhuis Antwerpen, Edegem
| | - M Mauer
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - A Roth
- Department of Surgery, Clinic for Visceral and Transplantation Surgery, Hôpital Universitaire de Genève, Geneva, Switzerland
| | - J P Neoptolemos
- Department of Surgery, University of Liverpool, Liverpool, UK
| | - M Lutz
- Caritasklinik St Theresia, Saarbrücken, Germany
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15
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Neoptolemos JP, Moore MJ, Cox TF, Valle JW, Palmer DH, Mcdonald A, Carter R, Tebbutt NC, Dervenis C, Smith D, Glimelius B, Coxon FY, Lacaine F, Middleton MR, Ghaneh P, Bassi C, Halloran C, Olah A, Rawcliffe CL, Büchler MW. Ampullary cancer ESPAC-3 (v2) trial: A multicenter, international, open-label, randomized controlled phase III trial of adjuvant chemotherapy versus observation in patients with adenocarcinoma of the ampulla of vater. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.18_suppl.lba4006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
LBA4006 Background: The effect of adjuvant treatment on overall survival (OS) of resected ampullary adenocarcinoma is not known. The aim was to compare the survival effect of adjuvant chemotherapy compared to observation (OBS) after resection and within the chemotherapy group to compare 5-fluorouracil/folinic acid (5-FU/FA) against gemcitabine (GEM). Methods: Patients were stratified by R0/R1 margins, randomised into three arms: (1) 5-FU/FA (FA, 20 mg/m2 iv bolus then 5-FU, 425 mg/m2, iv bolus, 1-5d every 28 days); (2) GEM (100mg/m2 iv infusion 1d, 8d and 15d every 4 weeks); (3) observation. The primary outcome measure was OS of chemotherapy versus no chemotherapy. 300 patients (200 chemotherapy and 100 observation) would provide 80% power to detect a 15% 5y survival difference, p<0.05. Results: 304 patients were randomised (July 2000 to April 2008), 199 to chemotherapy (101 5FU, 98 GEM) and 105 to observation. Median (range) age was 62 (35 – 81) years; 187 (61.5%) were men. Median (IQR) maximum tumour diameter was 20.0 (15.0 – 28.0) mm, 186 (63%) were moderately differentiated tumours, 174 (57%) had involved lymph nodes and 276 (91%) were R0 resections. Independent prognostic factors were tumour diameter and grade, lymph node status and R0/R1 status. Median (95% CI) OS for chemotherapy [57.1 (41.7 – 73.8) months] versus no chemotherapy [43.0 (27.6 - ) months] gave an HR (95% CI) of 0.85 (0.61 – 1.18), p=0.323. For R0 patients median (95% CI) OS for chemotherapy [58.4 (45.4 – 84.0) months] versus no chemotherapy [45.1 (26.7 - ) months] gave an HR (95% CI) of 0.78 (0.55 – 1.11), p=0.173. Cox proportional hazards modelling for all 304 patients p=0.161 and for 276 R0 patients p=0.057. Conclusions: This is the only large adjuvant trial ever conducted for ampullary adenocarcinoma. The results suggest a benefit for adjuvant monochemotherapy in patients with clear resection margins.
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Affiliation(s)
- J. P. Neoptolemos
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - M. J. Moore
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - T. F. Cox
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - J. W. Valle
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - D. H. Palmer
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - A. Mcdonald
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - R. Carter
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - N. C. Tebbutt
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - C. Dervenis
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - D. Smith
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - B. Glimelius
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - F. Y. Coxon
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - F. Lacaine
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - M. R. Middleton
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - P. Ghaneh
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - C. Bassi
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - C. Halloran
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - A. Olah
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - C. L. Rawcliffe
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
| | - M. W. Büchler
- University of Liverpool, Liverpool, United Kingdom; Department of Medical Oncology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom; CRUK Institute for Cancer Studies, Birmingham, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom; Glasgow Royal Infirmary, Glasgow, United Kingdom; Ludwig Oncology Unit, Austin Hospital, Heidelberg, Australia; Aiga Olga
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Neoptolemos JP, Moore MJ, Cox TF, Valle JW, Palmer DH, Mcdonald A, Carter R, Tebbutt NC, Dervenis C, Smith D, Glimelius B, Coxon FY, Lacaine F, Middleton MR, Ghaneh P, Bassi C, Halloran C, Olah A, Rawcliffe CL, Büchler MW. Ampullary cancer ESPAC-3 (v2) trial: A multicenter, international, open-label, randomized controlled phase III trial of adjuvant chemotherapy versus observation in patients with adenocarcinoma of the ampulla of vater. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.lba4006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Smith RA, Tang J, Tudur-Smith C, Neoptolemos JP, Ghaneh P. Meta-analysis of immunohistochemical prognostic markers in resected pancreatic cancer. Br J Cancer 2011; 104:1440-51. [PMID: 21448172 PMCID: PMC3101928 DOI: 10.1038/bjc.2011.110] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 03/02/2011] [Accepted: 03/08/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The potential prognostic value of several commonly investigated immunohistochemical markers in resected pancreatic cancer is variably reported. The objective of this study was to conduct a systematic review of literature evaluating p53, p16, smad4, bcl-2, bax, vascular endothelial growth factor (VEGF) and epidermal growth factor receptor (EGFR) expression as prognostic factors in resected pancreatic adenocarcinoma and to conduct a subsequent meta-analysis to quantify the overall prognostic effect. METHODS Relevant literature was identified using Medline, EMBASE and ISI Web of Science. The primary end point was overall survival assessed on univariate analysis. Only studies analysing resected pancreatic adenocarcinoma were eligible for inclusion and the summary log(e) hazard ratio (logHR) and variance were pooled using an inverse variance approach. Evidence of heterogeneity was evaluated using the χ(2) test for heterogeneity and its impact on the meta-analysis was assessed by the I(2) statisic. Hazard ratios greater than one reflect adverse survival associated with positive immunostaining. RESULTS Vascular endothelial growth factor emerged as the most potentially informative prognostic marker (11 eligible studies, n=767, HR=1.51 (95% confidence interval, CI=1.18-1.92)) with no evidence of any significant publication bias (Egger's test, P=0.269). Bcl-2 (5 eligible studies, n=314, HR=0.51 (95% CI=0.38-0.68)), bax (5 studies, n=274, HR=0.63 (95% CI=0.48-0.83)) and p16 (3 studies, n=229, HR=0.63 (95% CI=0.43-0.92)) also returned significant overall survival differences, but in smaller patient series due to a lack of evaluable literature. Neither p53 (17 studies, n=925, HR=1.22 (95% CI=0.96-1.56)), smad4 (5 studies, n=540, HR=0.88 (95% CI=0.61-1.27)) nor EGFR (4 studies, n=250, HR=1.35 (95% CI=0.80-2.27)) was found to represent significant prognostic factors when analysing the pooled patient data. There was evidence of significant heterogeneity in four of the seven study groups. CONCLUSION These results support the case for immunohistochemical expression of VEGF representing a significant and reproducible marker of adverse prognosis in resected pancreatic cancer.
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Affiliation(s)
- R A Smith
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor Duncan Building, Daulby Street, Liverpool L69 3GA, UK
| | - J Tang
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor Duncan Building, Daulby Street, Liverpool L69 3GA, UK
| | - C Tudur-Smith
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor Duncan Building, Daulby Street, Liverpool L69 3GA, UK
| | - J P Neoptolemos
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor Duncan Building, Daulby Street, Liverpool L69 3GA, UK
| | - P Ghaneh
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor Duncan Building, Daulby Street, Liverpool L69 3GA, UK
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18
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Slater EP, Langer P, Niemczyk E, Strauch K, Butler J, Habbe N, Neoptolemos JP, Greenhalf W, Bartsch DK. PALB2 mutations in European familial pancreatic cancer families. Clin Genet 2011; 78:490-4. [PMID: 20412113 DOI: 10.1111/j.1399-0004.2010.01425.x] [Citation(s) in RCA: 176] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Recently, PALB2 was reported to be a new pancreatic cancer susceptibility gene as determined by exomic sequencing, as truncating PALB2 mutations were identified in 3 of 96 American patients with familial pancreatic cancer (FPC). Representing the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC) and the German National Case Collection for Familial Pancreatic Cancer (FaPaCa), we evaluated whether truncating mutations could also be detected in European FPC families. We have directly sequenced the 13 exons of the PALB2 gene in affected index patients of 81 FPC families. An index patient was defined as the first medically identified patient, stimulating investigation of other members of the family to discover a possible genetic factor. None of these patients carried a BRCA2 mutation. We identified three (3.7%) truncating PALB2 mutations, each producing different stop codons: R414X, 508-9delAG and 3116delA. Interestingly, each of these three families also had a history of breast cancer. Therefore, PALB2 mutations might be causative for FPC in a small subset of European families, especially in those with an additional occurrence of breast cancer.
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Affiliation(s)
- E P Slater
- German National Case Collection of Familial Pancreatic Cancer (FaPaCa), Department of Surgery, Philipps-University, Marburg, Germany.
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19
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Dive C, Smith RA, Garner E, Ward T, George-Smith SS, Campbell F, Greenhalf W, Ghaneh P, Neoptolemos JP. Considerations for the use of plasma cytokeratin 18 as a biomarker in pancreatic cancer. Br J Cancer 2010; 102:577-82. [PMID: 20051949 PMCID: PMC2822934 DOI: 10.1038/sj.bjc.6605494] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 11/16/2009] [Accepted: 11/20/2009] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Enzyme-linked immunoassays of full-length (M65) and/or caspase-cleaved (M30) cytokeratin 18 (CK18) released from epithelial cells undergoing necrosis and/or apoptosis, respectively, may have prognostic or predictive biomarker utility in a range of solid tumour types. Characterisation of baseline levels of circulating full length and cleaved CK18 specifically in patients with pancreatic cancer. METHODS Plasma samples from 103 patients with pancreatic cancer stored at -80 degrees C were assayed for M65 and M30 levels. The median (inter-quartile range (IQR)) duration of plasma storage was 34 (23-57) months. Patients with metastatic disease (n=19) were found to have greater median (IQR) M65 levels (1145 (739-1698) U l(-1)) compared with the locally advanced (n=20; 748 (406-1150) U l(-1)) and resected (n=64; 612 (331-987) U l(-1)) patients (P=0.002). Elevated M65 levels were associated with poorer overall survival on univariate (P<0.001) but not multivariate (P=0.202) analysis. M65 concentrations also exhibited significant associations with concurrent serum-bilirubin levels (P<0.001) and the duration of plasma storage (P<0.001). CONCLUSIONS Baseline plasma CK18 levels in pancreatic cancer are affected by the presence of obstructive jaundice and prolonged plasma storage. Clinical biomarker studies utilising serial CK18 levels are warranted in pancreatic cancer, provided consideration is given to these potentially confounding factors.
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Affiliation(s)
- C Dive
- Clinical and Experimental Pharmacology Group, Paterson Institute for Cancer Research, University of Manchester, Manchester, UK
| | - R A Smith
- Liverpool Experimental Cancer Medicines Centre and NIHR Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, 5th Floor UCD Building, Daulby St, Liverpool L69 3GA, UK
| | - E Garner
- Liverpool Experimental Cancer Medicines Centre and NIHR Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, 5th Floor UCD Building, Daulby St, Liverpool L69 3GA, UK
| | - T Ward
- Clinical and Experimental Pharmacology Group, Paterson Institute for Cancer Research, University of Manchester, Manchester, UK
| | - S St George-Smith
- Clinical and Experimental Pharmacology Group, Paterson Institute for Cancer Research, University of Manchester, Manchester, UK
| | - F Campbell
- Department of Pathology, Royal Liverpool University Hospital, Prescot St, Liverpool L7 8XP, UK
| | - W Greenhalf
- Liverpool Experimental Cancer Medicines Centre and NIHR Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, 5th Floor UCD Building, Daulby St, Liverpool L69 3GA, UK
| | - P Ghaneh
- Liverpool Experimental Cancer Medicines Centre and NIHR Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, 5th Floor UCD Building, Daulby St, Liverpool L69 3GA, UK
| | - J P Neoptolemos
- Liverpool Experimental Cancer Medicines Centre and NIHR Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, 5th Floor UCD Building, Daulby St, Liverpool L69 3GA, UK
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20
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Johnson CD, Berry DP, Harris S, Pickering RM, Davis C, George S, Imrie CW, Neoptolemos JP, Sutton R. An open randomized comparison of clinical effectiveness of protocol-driven opioid analgesia, celiac plexus block or thoracoscopic splanchnicectomy for pain management in patients with pancreatic and other abdominal malignancies. Pancreatology 2010; 9:755-63. [PMID: 20090396 DOI: 10.1159/000199441] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Accepted: 01/23/2009] [Indexed: 12/11/2022]
Abstract
UNLABELLED In inoperable malignancy, pain relief with opioids is often inadequate. Nerve block procedures may improve symptom control. Our aim was to assess celiac plexus block (CPB) and thoracoscopic splanchnicectomy (TS) in patients receiving appropriate medical management (MM). METHODS Patients with confirmed irresectable malignancy of the pancreas or upper abdominal viscera who required opioid analgesia were randomized to MM alone, MM+CPB, or MM+TS. Randomization was stratified by treatment centre, tumour type and previous opioid medication. The primary endpoint was pain relief at 2 months. RESULTS 65 patients (58 pancreas cancer) were randomized, 18 withdrew or died within 2 months. Effective pain relief was achieved in only one third of subjects at 2 weeks, and just under half at 2 months (MM: 6/19 and 5/12 evaluable patients; CPB: 5/14 and 5/9; TS 4/14 and 4/11). There were no significant differences between the groups in pain scores or opioid consumption, and there was no correlation between continued use of opioids and effective pain relief. DISCUSSION Previous randomized studies have shown small differences in pain scores, but no difference in opioid consumption and quality of life. The absence of any benefit from interventions in the present study questions their value.
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Affiliation(s)
- Colin D Johnson
- University Surgical Unit (816), Southampton General Hospital, Southampton, UK.
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21
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Neoptolemos JP, Stocken DD, Tudur Smith C, Bassi C, Ghaneh P, Owen E, Moore M, Padbury R, Doi R, Smith D, Büchler MW. Adjuvant 5-fluorouracil and folinic acid vs observation for pancreatic cancer: composite data from the ESPAC-1 and -3(v1) trials. Br J Cancer 2009; 100:246-50. [PMID: 19127260 PMCID: PMC2625958 DOI: 10.1038/sj.bjc.6604838] [Citation(s) in RCA: 154] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The ESPAC-1, ESPAC-1 plus, and early ESPAC-3(v1) results (458 randomized patients; 364 deaths) were used to estimate the effectiveness of adjuvant 5FU/FA vs resection alone for pancreatic cancer using meta-analysis. The pooled hazard ratio of 0.70 (95% CI=0.55-0.88) P=0.003, and the median survival of 23.2 (95% CI=20.1-26.5) months with 5FU/FA vs 16.8 (95% CI=14.3-19.2) months with resection alone supports the use of adjuvant 5FU/FA in pancreatic cancer.
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Affiliation(s)
- J P Neoptolemos
- CR-UK Liverpool Cancer Trials Unit, University of Liverpool Cancer Research Centre, Liverpool, UK.
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22
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Al-Sarireh B, Ghaneh P, Gardner-Thorpe J, Raraty M, Hartley M, Sutton R, Neoptolemos JP. Complications and follow-up after pancreas-preserving total duodenectomy for duodenal polyps. Br J Surg 2008; 95:1506-11. [DOI: 10.1002/bjs.6412] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Patients with duodenal polyps are at risk of duodenal cancer. Pancreas-preserving total duodenectomy (PPTD) is an alternative to partial pancreatoduodenectomy.
Methods
Twelve patients (seven men and five women) with a median age of 59 (interquartile range (i.q.r.) 50–67) years underwent PPTD for large (over 20 mm) solitary polyps or multiple (more than three) duodenal polyps confined to the muscularis propria on endoscopic ultrasonography.
Results
Median hospital stay was 21 (i.q.r. 10–36) days with no deaths and no blood transfusion. Six patients developed postoperative complications, one requiring reoperation. Histology demonstrated gastrointestinal stromal tumour in three patients, low-grade dysplasia in one, moderate-grade dysplasia in eight and duodenal intramucosal adenocarcinoma in one. During a median follow-up of 20 (i.q.r. 8–41) months one patient experienced recurrent acute pancreatitis (due to hypertriglyceridaemia) and one developed a jejunal adenocarcinoma in the neoduodenum.
Conclusion
The morbidity of PPTD is similar to that of partial pancreatoduodenectomy, but PPTD preserves the whole pancreas and reduces the number of anastomoses.
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Affiliation(s)
- B Al-Sarireh
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - P Ghaneh
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - J Gardner-Thorpe
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - M Raraty
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - M Hartley
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - R Sutton
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
| | - J P Neoptolemos
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Royal Liverpool University Hospital, 5th Floor University Clinical Departments Building, Daulby Street, Liverpool, L69 3GA, UK
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23
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Smith RA, Dajani K, Dodd S, Whelan P, Raraty M, Sutton R, Campbell F, Neoptolemos JP, Ghaneh P. Preoperative resolution of jaundice following biliary stenting predicts more favourable early survival in resected pancreatic ductal adenocarcinoma. Ann Surg Oncol 2008; 15:3138-46. [PMID: 18787902 DOI: 10.1245/s10434-008-0148-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 08/12/2008] [Accepted: 08/12/2008] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Despite the widespread use of endoscopic biliary stenting in patients presenting with potentially resectable pancreatic cancer, there is no general consensus regarding whether this represents a superior management approach over expeditious surgical intervention. The objective of this study was to investigate the influence of preoperative biliary stenting and resolution of jaundice on subsequent postoperative survival following resection for pancreatic cancer. METHODS 155 patients undergoing partial pancreatoduodenectomy for pancreatic ductal adenocarcinoma between January 1997 and August 2007 were identified from a prospectively maintained database. RESULTS There was no survival difference when comparing patients undergoing preoperative biliary drainage (n = 130) with those who did not (n = 25) (log rank, P = 0.981). When analysing individual prognostic factors as continuous variables in univariate Cox analysis, lower albumin levels (P = 0.016), elevated alkaline phosphatase levels (P = 0.011) and elevated CRP levels (P = 0.021) were associated with poorer overall survival. Multivariable Cox regression demonstrated that both albumin (P = 0.008) and CRP (P = 0.038) remained significant independent predictors of overall survival alongside lymph node ratio (P = 0.018). Although preoperative bilirubin levels were not associated with overall survival when analysed as a continuous variable (Cox, P = 0.786), the presence of jaundice (i.e., bilirubin >35 micromol/l) at the time of surgery was a significant adverse predictor of early survival in patients undergoing preoperative biliary drainage (Breslow-Gehan-Wilcoxon, P = 0.013) and remained a significant predictor of early survival when included in a further Cox analysis with censoring of cases who survived beyond 6 months (Cox, P = 0.017). CONCLUSION These results suggest that the presence of jaundice at the time of resection has an adverse impact on early, but not overall, postoperative survival in pancreatic cancer patients undergoing preoperative biliary drainage.
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Affiliation(s)
- Richard A Smith
- Division of Surgery and Oncology, School of Cancer Studies, Royal Liverpool University Hospital, 5th Floor UCD Building, Daulby St, Liverpool L69 3GA, UK.
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Sultana A, Tudur Smith C, Cunningham D, Starling N, Neoptolemos JP, Ghaneh P. Meta-analyses of chemotherapy for locally advanced and metastatic pancreatic cancer: results of secondary end points analyses. Br J Cancer 2008; 99:6-13. [PMID: 18577990 PMCID: PMC2453014 DOI: 10.1038/sj.bjc.6604436] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/28/2008] [Accepted: 05/02/2008] [Indexed: 12/12/2022] Open
Abstract
In advanced pancreatic cancer, level one evidence has established a significant survival advantage with chemotherapy, compared to best supportive care. The treatment-associated toxicity needs to be evaluated. This study examines the secondary outcome measures for chemotherapy in advanced pancreatic cancer using meta-analyses. A systematic review was undertaken employing Cochrane methodology, with search of databases, conference proceedings and trial registers. The secondary end points were progression-free survival (PFS)/time to progression (TTP) (summarised using the hazard ratio (HR)), response rate and toxicity (summarised using relative risk). There was no significant advantage of 5FU combinations vs 5FU alone for TTP (HR=1.02; 95% CI=0.85-1.23) and toxicity. Progression-free survival (HR 0.78; CI 0.70-0.88), TTP (HR=0.85; 95% CI=0.72-0.99) and overall response rate (RR=0.56; 95% CI=0.46-0.68) were significantly better for gemcitabine combination chemotherapy, but offset by the greater grade 3/4 toxicity thrombocytopenia (RR=1.94; 95% CI=1.32-2.84), leucopenia (RR=1.46; 95% CI=1.15-1.86), neutropenia (RR=1.48; 95% CI=1.07-2.05), nausea (RR=1.77; 95% CI=1.37-2.29), vomiting (RR=1.64; 95% CI=1.24-2.16) and diarrhoea (RR=2.73; 95% CI=1.87-3.98). There is no significant advantage on secondary end point analyses for administering 5FU in combination over 5FU alone. There is improved PFS/TTP and response rate, with gemcitabine-based combinations, although this comes with greater toxicity.
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Affiliation(s)
- A Sultana
- CRUK Liverpool Cancer Trials Unit, Cancer Research Centre, 200 London Road, Liverpool, L3 9TA, UK
| | - C Tudur Smith
- CRUK Liverpool Cancer Trials Unit, Cancer Research Centre, 200 London Road, Liverpool, L3 9TA, UK
- Centre for Medical Statistics and Health Evaluation, University of Liverpool, Shelley's Cottage, Brownlow Street, Liverpool L69 3GS, UK
| | - D Cunningham
- Department of Medicine, Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - N Starling
- Department of Medicine, Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - J P Neoptolemos
- CRUK Liverpool Cancer Trials Unit, Cancer Research Centre, 200 London Road, Liverpool, L3 9TA, UK
| | - P Ghaneh
- CRUK Liverpool Cancer Trials Unit, Cancer Research Centre, 200 London Road, Liverpool, L3 9TA, UK
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Smith RA, Bosonnet L, Ghaneh P, Raraty M, Sutton R, Campbell F, Neoptolemos JP. Preoperative CA19-9 levels and lymph node ratio are independent predictors of survival in patients with resected pancreatic ductal adenocarcinoma. Dig Surg 2008; 25:226-32. [PMID: 18577869 DOI: 10.1159/000140961] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Accepted: 02/29/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to identify whether preoperative CA19-9 levels might represent an independent prognostic marker for overall survival in patients undergoing resection for pancreatic ductal adenocarcinoma, and to describe the relationship between CA19-9 and tumour histology. METHODS 109 patients who had a pancreatoduodenectomy for pancreatic ductal adenocarcinoma with recorded preoperative CA19-9 levels were identified from a prospectively maintained database (1997-2006). Multivariate analysis was conducted using a Cox proportional hazards model with continuous covariates where possible. RESULTS The median survival of 64 patients with a preoperative CA19-9 level >150 kU/l was 10.4 months while in 45 patients with a CA19-9 level <or=150 kU/l this was 22.1 months (corrected p = 0.012). Also significant on univariate analyses were overall lymph node status (p = 0.011), lymph node ratio (p = 0.003) and tumour diameter (p = 0.004). Preoperative CA19-9 levels >150 kU/l were associated with a larger, more poorly differentiated tumour along with an increased likelihood of a positive resection margin status (all p < 0.05). Preoperative CA19-9 levels (p = 0.030) and lymph node ratio (p = 0.042) emerged as independent predictors of survival on multivariate analysis. CONCLUSIONS Preoperative CA19-9 levels and lymph node ratio were significant predictors of survival in resected pancreatic ductal adenocarcinoma.
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Affiliation(s)
- R A Smith
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Liverpool, UK
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George-Smith SS, Smith RA, Greenhalf W, Smith N, Ghaneh P, Neoptolemos JP, Dive C. Clinical utility of blood-borne markers of epithelial cell death in pancreatic cancer. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.22056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Halloran CM, Ghaneh P, Connor S, Sutton R, Neoptolemos JP, Raraty MGT. Carbohydrate antigen 19.9 accurately selects patients for laparoscopic assessment to determine resectability of pancreatic malignancy. Br J Surg 2008; 95:453-9. [PMID: 18161888 DOI: 10.1002/bjs.6043] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Laparoscopy with laparoscopic ultrasonography (L-LUS) may be useful in the selection of patients for surgery to resect peripancreatic malignancy in addition to contrast-enhanced computed tomography (CE-CT). The present prospective study assessed the strategy of using carbohydrate antigen 19.9 (CA19.9) levels to select patients for L-LUS. METHODS Patients with suspected peripancreatic malignancy that appeared resectable on CE-CT were selected for immediate surgery if CA19.9 was low (up to 150 kU/l, or up to 300 kU/l if serum bilirubin was above 35 micromol/l), or to L-LUS if CA19.9 was high (over 150 kU/l, or over 300 kU/l if serum bilirubin was above 35 micromol/l). Data were assessed to determine the clinical utility of this strategy. RESULTS A total of 94 patients went straight to surgery, of whom 65 proved resectable: 63 of 80 with a low CA19.9 level but only two of 14 with a high CA19.9 level and gastric outlet obstruction. From 55 patients with high CA19.9 levels, L-LUS correctly identified 26 of 31 resectable tumours and eight of 24 unresectable tumours. CONCLUSION Using CA19.9 levels to help select patients with pancreatic malignancy for immediate surgery or L-LUS for further assessment of resectability effectively increased resection rates and reduced unnecessary laparotomies.
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Affiliation(s)
- C M Halloran
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, Liverpool, UK
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Abstract
Pancreatic neuroendocrine tumours are rare tumours ( approximately 1/100,00 population/year) of which 60% are non-functioning. Except for insulinoma all types are malignant in >50% of cases. In multiple endocrine neoplasia (MEN)1, pancreatic neuroendocrine tumours occur in 40-80% of patients and are mostly non-functioning tumours or gastrinomas. Insulinomas are benign in approximately 90%, solitary in 95% of sporadic cases whilst multiple in 90% of MEN1 patients. In contrast approximately 50% gastrinomas and the majority of non-functioning pancreatic neuroendocrine tumours are malignant. Pancreatic neuroendocrine tumours occur in 10-15% of patients with Von Hippel-Lindau (VHL) and are frequently multiple (>30%). Surgical excision is a key aspect of treatment for all cases of sporadic gastrinoma and if >2.5 cm in MEN1. Insulinomas are enucleated if solitary and may require pancreatectomy if multiple. Non-functioning tumours should also be resected if sporadic and if >2 cm in MEN1 or if >2-3 cm in VHL. Tumours <1cm require yearly follow-up by CT or MRI from an early age in VHL. The local treatment for liver metastases is now well established and options include liver resection, chemoembolisation and radiofrequency ablation. Systemic therapies have also been better defined and include radionuclide therapy against somatostatin receptors or MIBG and chemotherapy especially for poorly differentiated tumours. A number of novel agents are currently in clinical development.
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Affiliation(s)
- N Alexakis
- General Surgery, University of Athens, Greece
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Abstract
Ductal adenocarcinoma of the pancreas is one of the leading causes of cancer death in the UK, Europe and US, with incidence closely paralleling mortality. Until recently, enthusiasm for treating these patients was limited for a number of reasons: the majority of patients undergoing surgery would relapse early, adjuvant treatment was of unproven value and systemic therapy in advanced disease had only a small chance of a short-term benefit. More recently, however, it has become recognised that specialist surgery can improve results and there is evidence that adjuvant chemotherapy has a significant advantage in terms of 5-year survival. In particular adjuvant systemic 5-fluorouracil with folinic acid can result in 5-year survival of < or = 29% (compared with 11% for controls) and adjuvant gemcitabine can improve disease-free survival to 13.4 months from a median of 6.9 months in controls, but not overall survival. In contrast the role of adjuvant chemoradiation in addition to chemotherapy remains unproven and the survival results appear to be inferior to systemic chemotherapy alone. New agents, such as capecitabine and erlotinib, are emerging with some activity in this dismal disease signalling hope for the future.
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Affiliation(s)
- Kyaw L Aung
- Clatterbridge Centre for Oncology, Bebington, Wirral, Merseyside, CH63 4JY, UK.
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Alexakis N, Lombard M, Raraty M, Ghaneh P, Smart HL, Gilmore I, Evans J, Hughes M, Garvey C, Sutton R, Neoptolemos JP. When is pancreatitis considered to be of biliary origin and what are the implications for management? Pancreatology 2007; 7:131-41. [PMID: 17592225 DOI: 10.1159/000104238] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis is a disease caused by gallstones in 40-60% of patients. Identification of these patients is extremely important, since there are specific therapeutic interventions by endoscopic sphincterotomy and/or cholecystectomy. The combination of trans-abdominal ultrasound (stones in the gallbladder and/or main bile duct) and elevated serum alanine transaminase (circa >60 IU/l within 48 h of presentation) indicates gallstones as the cause in the majority of patients with acute pancreatitis. In the presence of a severe attack this is a strong indication for intervention by endoscopic sphincterotomy. The presence of a significant main bile duct dilatation is also strongly indicative of gallstones and should prompt the use of endoluminal ultrasonography: >8 mm diameter with gallbladder in situ, or >10 mm following cholecystectomy if aged <70 years and >12 mm, respectively, if > or = 70 years. In mild pancreatitis surgically fit patients should be treated by cholecystectomy, and intra-operative cholangiography, as pre-operative biliary imaging is not efficient in this setting. Patients who are not fit for cholecystectomy should undergo prophylactic endoscopic sphincterotomy to prevent further attacks. In the post-acute-phase, pancreatitis patients in whom the aetiology is uncertain should undergo endoluminal ultrasonography. Thisis the most sensitive method for the detection of cholelithiasis and choledocholithiasis and may reveal alternative aetiological factors such as a small ampullary or pancreatic cancer. A number of recent studies have shown that bile crystal analysis, a marker for microlithiasis, increases the yield of positive results over and above endoluminal ultrasonography, and should be considered as part of the modern investigative algorithm.
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Affiliation(s)
- N Alexakis
- Division of Surgery and Oncology, University of Liverpool, Royal Liverpool University Hospital, Liverpool, UK
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Sultana A, Tudur Smith C, Cunningham D, Starling N, Tait D, Neoptolemos JP, Ghaneh P. Systematic review, including meta-analyses, on the management of locally advanced pancreatic cancer using radiation/combined modality therapy. Br J Cancer 2007; 96:1183-90. [PMID: 17406358 PMCID: PMC2360143 DOI: 10.1038/sj.bjc.6603719] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Revised: 03/08/2007] [Accepted: 03/08/2007] [Indexed: 12/17/2022] Open
Abstract
There is no consensus on the management of locally advanced pancreatic cancer, with either chemotherapy or combined modality approaches being employed (Maheshwari and Moser, 2005). No published meta-analysis (Fung et al, 2003; Banu et al, 2005; Liang, 2005; Bria et al, 2006; Milella et al, 2006) has included randomised controlled trials employing radiation therapy. The aim of this systematic review was to compare the following: (i) chemoradiation followed by chemotherapy (combined modality therapy) vs best supportive care (ii) radiotherapy vs chemoradiation (iii) radiotherapy vs combined modality therapy (iv) chemotherapy vs combined modality therapy (v) 5FU-based combined modality treatment vs another-agent-based combined modality therapy. Relevant randomised controlled trials were identified by searching databases, trial registers and conference proceedings. The primary end point was overall survival and secondary end points were progression-free survival/time-to-progression, response rate and adverse events. Survival data were summarised using hazard ratio (HR) and response-rate/adverse-event data with relative risk. Eleven trials involving 794 patients met the inclusion criteria. Length of survival with chemoradiation was increased compared with radiotherapy alone (two trials, 168 patients, HR 0.69; 95% confidence interval (CI) 0.51-0.94), but chemoradiation followed by chemotherapy did not lead to a survival advantage over chemotherapy alone (two trials, 134 patients, HR 0.79; CI 0.32-1.95). Meta-analyses could not be performed for the other comparisons. A survival benefit was demonstrated for chemoradiation over radiotherapy alone. Chemoradiation followed by chemotherapy did not demonstrate any survival advantage over chemotherapy alone, but important clinical differences cannot be ruled out due to the wide CI.
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Affiliation(s)
- A Sultana
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, 5th Floor-UCD Building, Daulby Street, Liverpool L69 3GA, UK
| | - C Tudur Smith
- Centre for Medical Statistics and Health Evaluation, University of Liverpool, Shelley's Cottage, Brownlow Street, Liverpool L69 3GS, UK
| | - D Cunningham
- Department of Medicine, Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - N Starling
- Department of Medicine, Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - D Tait
- Department of Clinical Oncology, Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - J P Neoptolemos
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, 5th Floor-UCD Building, Daulby Street, Liverpool L69 3GA, UK
| | - P Ghaneh
- Division of Surgery and Oncology, School of Cancer Studies, University of Liverpool, 5th Floor-UCD Building, Daulby Street, Liverpool L69 3GA, UK
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Abstract
BACKGROUND Cancer risk, including pancreatic, is high in those with Peutz-Jeghers syndrome (PJS). It has been suggested that such patients should undergo screening for pancreatic cancer. METHODS The risk of pancreatic cancer in PJS, pancreatic screening and potential screening strategies were reviewed. Cost-effectiveness was assessed according to American Gastroenterology Association guidelines and a risk stratification model proposed by the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer. RESULTS The risk of pancreatic cancer is increased in PJS but screening would cost over US 35,000 dollars per life saved. Risk stratification reduces cost by 100,000 dollars and costs fall to 50,000 dollars per life saved if deaths from other forms of cancer are avoided. CONCLUSION Screening should be performed only on a research basis to evaluate the benefit and cost-effectiveness in high-risk groups.
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Affiliation(s)
- A Latchford
- Polyposis Registry, St Mark's Hospital, Northwick Park, Harrow, UK
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Grocock CJ, Vitone LJ, Harcus MJ, Neoptolemos JP, Raraty MGT, Greenhalf W. Familial pancreatic cancer: a review and latest advances. Adv Med Sci 2007; 52:37-49. [PMID: 18217388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Familial Pancreatic Cancer (FPC) is the autosomal dominant inheritance of a genetic predisposition to pancreatic ductal adenocarcinoma, penetrance is assumed to be high but not complete. It was first described in 1987 and since then many families have been identified, but the candidate disease gene remains elusive and the very existence of the syndrome is sometimes questioned. FPC identifies a target group for secondary screening. As well as being potentially life saving for the subjects, screening offers researchers the opportunity to elucidate the early pathogenesis of pancreatic cancer. The scientific incentive for screening should not blind us to the challenges facing clinicians in managing high risk patients. Early surgical treatment may dramatically improve the five year survival for pancreatic cancer, but this must be balanced against the risks of false positives, where healthy individuals are subjected to the mortality and morbidity of major pancreatic surgery.
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Affiliation(s)
- C J Grocock
- Division of Surgery & Oncology, The University of Liverpool, United Kingdom
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Abstract
BACKGROUND Previous studies of anticipation in familial pancreatic cancer have been small and subject to ascertainment bias. Our aim was to determine evidence for anticipation in a large number of European families. PATIENTS AND METHODS A total of 1223 individuals at risk from 106 families (264 affected individuals) were investigated. Generation G3 was defined as the latest generation that included any individual aged over 39 years; preceding generations were then defined as G2 and G1. RESULTS With 80 affected child-parent pairs, the children died a median (interquartile range) of 10 (7, 14) years earlier. The median (interquartile range) age of death from pancreatic cancer was 70 (59, 77), 64 (57, 69), and 49 (44, 56) years for G1, G2, and G3, respectively. These indications of anticipation could be the result of bias. Truncation of Kaplan-Meier analysis to a 60 year period to correct for follow up time bias and a matched test statistic indicated significant anticipation (p=0.002 and p<0.001). To minimise bias further, an iterative analysis to predict cancer numbers was developed. No single risk category could be applied that accurately predicted cancer cases in every generation. Using three risk categories (low with no pancreatic cancer in earlier generations, high with a single earlier generation, and very high where two preceding generations were affected), incidence was estimated without significant error. Anticipation was independent of smoking. CONCLUSION This study provides the first strong evidence for anticipation in familial pancreatic cancer and must be considered in genetic counselling and the commencement of secondary screening for pancreatic cancer.
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Affiliation(s)
- C D McFaul
- Division of Surgery and Oncology, University of Liverpool L69 3GA, UK
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Neoptolemos JP. Oxford textbook of surgery volumes 1 and 2. P. J. Morris and R. A. Malt (eds). 280×230 mm. Pp. 2754. Illustrated. 1994. Oxford: Oxford University Press. £125. Br J Surg 2005. [DOI: 10.1002/bjs.1800820362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Affiliation(s)
| | - I A Donovan
- Dudley Road Hospital, Birmingham B18 7QH, UK
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38
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Neoptolemos JP. Illustrated terminology, definitions and diagnostic criteria in digestive endoscopy. Z. Maratka (ed.). 245 × 168 mm. Pp. 64. Illustrated. 1992. Bad Homburg: Normed Verlag. DM69. Br J Surg 2005. [DOI: 10.1002/bjs.1800800147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Neoptolemos JP, Russell RCG, Bramhall S, Theis B. Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units. Br J Surg 2005. [DOI: 10.1111/j.1365-2168.1997.00504.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Neoptolemos JP. Surgical decision making. 3rd ed. L. W. Norton, G. Steele Jr and B. Eiseman (eds). 220 × 280 mm. Pp. 342. Not illustrated. 1993. Philadelphia, Pennsylvania: W. B. Saunders. £55. Br J Surg 2005. [DOI: 10.1002/bjs.1800801149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Bassi C, Stocken DD, Olah A, Friess H, Buckels J, Hickey H, Dervenis C, Dunn JA, Deakin M, Carter R, Ghaneh P, Neoptolemos JP, Buchler MW. Influence of surgical resection and post-operative complications on survival following adjuvant treatment for pancreatic cancer in the ESPAC-1 randomized controlled trial. Dig Surg 2005; 22:353-63. [PMID: 16293966 DOI: 10.1159/000089771] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Accepted: 08/05/2005] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS The influence of type of surgery and occurrence of post-operative complications on survival following adjuvant therapy for pancreatic cancer are uncertain. METHODS Cox proportional hazard modelling was used to investigate the influence of type of surgery and the presence of complications on survival in conjunction with clinico-pathological variables in the 550 patients of the ESPAC-1 adjuvant randomized controlled trial. RESULTS Standard Kausch-Whipple (KW) was performed in 282 (54%) patients, 186 (35%) had a pylorus-preserving (PP) KW, 39 (7%) had a distal pancreatectomy and 21 (4%) had a total pancreatectomy. Post-operative complications were reported in 140 (27%) patients. PP-KW patients survived longer with a median (95% CI) survival of 19.9 (17.3, 23.1) months compared to 14.8 (13.0, 16.7) for KW patients (chi(2)(LR) = 15.1, p < 0.001). KW patients were more likely however to have R1 margins (67 (24%) vs. 29 (16%), chi(2) = 4.59, p = 0.032), poorly differentiated tumours (70 (26%) vs. 19 (10%), chi(2) = 18.65, p < 0.001) and positive lymph nodes (165 (60%) vs. 81 (44%), chi(2) = 11.32, p < 0.001). Post-operative complications did not significantly affect survival. Independent prognostic factors were tumour grade, nodal status and tumour size but not type of surgery or post-operative complications. There was a survival benefit for chemotherapy irrespective of the type of surgery or post-operative complications. CONCLUSIONS The KW and PP-KW procedures did not significantly influence the hazard of death in the presence of tumour staging, demonstrating that ESPAC-1 surgeons showed good judgement in their choice of operation. Post-operative complications did not adversely affect the survival benefit from adjuvant chemotherapy.
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Affiliation(s)
- C Bassi
- Surgical Department, Endocrine and Pancreatic Unit, University of Verona, Verona, Italy
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Abstract
Gallstones are the commonest cause of acute pancreatitis in developed countries. There is now a considerable evidence base consolidated by a series of systematic reviews, meta-analyses and guidelines that has established a clear algorithm for diagnosis and management. In the majority of patients the combination of ultrasonography and serum alanine transaminase > or = 60 iu/l < or = 48 hours of symptoms will identify gallstones as the cause. The simplest method of severity assessment is a high level of serum C-reactive protein (> 150 mg/l up to 72 hours after symptoms). In mild disease, all fit patients must undergo laparoscopic cholecystectomy with intraoperative cholangiography or if not fit for surgery then endoscopic sphincterotomy during the same admission to prevent further attacks. All patients with severe disease should undergo endoscopic sphincterotomy in less than 72 hours. Patients with > 30% necrosis should undergo fine needle aspiration for bacteriology. Necrosectomy is indicated for infected necrosis or sterile necrosis if there are persisting clinically significant symptoms. There is increasing evidence for the use of minimally invasive pancreatic necrosectomy. Enteral nutrition should be instituted whenever possible but antibiotics should be reserved for patients with proven sepsis. The presence of fungal infection requires active anti-fungal therapy. Patients with severe disease should undergo cholecystectomy at a later stage. Patients who have undergone necrosectomy require long-term follow-up because of delayed complications.
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Affiliation(s)
- N Alexakis
- Division of Surgery and Oncology, University of Liverpool, Liverpool, UK
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Connor S, Raraty MGT, Howes N, Evans J, Ghaneh P, Sutton R, Neoptolemos JP. Surgery in the treatment of acute pancreatitis--minimal access pancreatic necrosectomy. Scand J Surg 2005; 94:135-42. [PMID: 16111096 DOI: 10.1177/145749690509400210] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Between 5% and 10% of patients with acute pancreatitis will develop infected pancreatic necrosis. Traditional open surgery for this condition carries a mortality rate of up to 50%, and therefore a number of less invasive techniques have been developed, including radiological drainage and a minimal access retroperitoneal approach. No randomised controlled trials have been published which compare these techniques. Indications for minimal access surgery are the same as for open surgery, i.e. infected pancreatic necrosis or failure to improve with extensive sterile necrosis. Access is obtained to the pancreatic necrosis via the left loin and necrosectomy performed using an operating nephroscope, and this often requires several procedures to remove all necrotic tissue. The cavity is continuously irrigated on the ward in between procedures. The results of this approach are encouraging, with less systemic upset to the patient, a lower incidence of post-operative organ failure when compared with open surgery, and a reduced requirement for ITU support. There is also a trend towards a lower mortality rate, although this does not reach statistical significance on the data published so far. Current evidence suggests that a minimal access approach to pancreatic necrosis is feasible, well tolerated and beneficial for the patient when compared with open surgery.
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Affiliation(s)
- S Connor
- Division of Surgery and Oncology, University of Liverpool, Liverpool, UK
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Stocken DD, Büchler MW, Dervenis C, Bassi C, Jeekel H, Klinkenbijl JHG, Bakkevold KE, Takada T, Amano H, Neoptolemos JP. Meta-analysis of randomised adjuvant therapy trials for pancreatic cancer. Br J Cancer 2005; 92:1372-81. [PMID: 15812554 PMCID: PMC2361989 DOI: 10.1038/sj.bjc.6602513] [Citation(s) in RCA: 234] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The aim of this study was to investigate the worldwide evidence of the roles of adjuvant chemoradiation and adjuvant chemotherapy on survival in potentially curative resected pancreatic cancer. Five randomised controlled trials of adjuvant treatment in patients with histologically proven pancreatic ductal adenocarcinoma were identified, of which the four most recent trials provided individual patient data (875 patients). This meta-analysis includes previously unpublished follow-up data on 261 patients. The pooled estimate of the hazard ratio (HR) indicated a 25% significant reduction in the risk of death with chemotherapy (HR=0.75, 95% confidence interval (CI): 0.64, 0.90, P-valuesstratified (Pstrat)=0.001) with median survival estimated at 19.0 (95% CI: 16.4, 21.1) months with chemotherapy and 13.5 (95% CI: 12.2, 15.8) without. The 2- and 5-year survival rates were estimated at 38 and 19%, respectively, with chemotherapy and 28 and 12% without. The pooled estimate of the HR indicated no significant difference in the risk of death with chemoradiation (HR=1.09, 95% CI: 0.89, 1.32, Pstrat=0.43) with median survivals estimated at 15.8 (95% CI: 13.9, 18.1) months with chemoradiation and 15.2 (95% CI: 13.1, 18.2) without. The 2- and 5-year survival rates were estimated at 30 and 12%, respectively, with chemoradiation and 34 and 17% without. Subgroup analyses estimated that chemoradiation was more effective and chemotherapy less effective in patients with positive resection margins. These results show that chemotherapy is effective adjuvant treatment in pancreatic cancer but not chemoradiation. Further studies with chemoradiation are warranted in patients with positive resection margins, as chemotherapy appeared relatively ineffective in this patient subgroup.
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Affiliation(s)
- D D Stocken
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - M W Büchler
- University of Heidelberg, Heidelberg, Germany
| | | | - C Bassi
- University of Verona, Verona, Italy
| | - H Jeekel
- University Hospital Rotterdam, Rotterdam, The Netherlands
| | | | | | - T Takada
- Teikyo University School of Medicine, Teikyo, Japan
| | - H Amano
- Teikyo University School of Medicine, Teikyo, Japan
| | - J P Neoptolemos
- University of Liverpool, Liverpool, UK
- Department of Surgery, Royal Liverpool University Hospital, 5th floor UCD Building, Daulby Street, Liverpool L69 3GA, UK. E-mail:
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Connor S, Alexakis N, Raraty MGT, Ghaneh P, Evans J, Hughes M, Garvey CJ, Sutton R, Neoptolemos JP. Early and late complications after pancreatic necrosectomy. Surgery 2005; 137:499-505. [PMID: 15855920 DOI: 10.1016/j.surg.2005.01.003] [Citation(s) in RCA: 183] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgery for pancreatic necrosis is associated with a high morbidity and mortality. The aim of this study was to review the incidence of early and late complications after pancreatic necrosectomy in a large contemporary series of patients. METHODS The clinical outcomes of 88 patients who underwent pancreatic necrosectomy between 1997 and 2003 were reviewed. RESULTS The median age was 55.5 (range, 18-85) years, 54 (61%) were males, 68 (77%) had primary pancreatic infection, 71 (81%) had >50% necrosis, and the median admission Acute Physiology and Chronic Health Evaluation score was 9 (range, 1-21). Median time to surgery was 31 (range, 1-161) days; 47 patients underwent minimally invasive necrosectomy and 41 open necrosectomy; 81 (92%) of patients had complications postoperatively, and 25 (28%) died. Multiorgan failure (odds ratio = 3.4, P = .05) and hemorrhage (odds ratio = 6.1, P = .03) were the only independent predictors of mortality. During a median follow-up of 28.9 months, 39 (62%) of 63 surviving patients had one or more late complications: biliary stricture in 4 (6%), pseudocyst in 5 (8%), pancreatic fistula in 8 (13%), gastrointestinal fistula in 1 (2%), delayed collections in 3 (5%), and incisional hernia in 1 (2%); intervention was required in 10 (16%) patients. Sixteen (25%) of 63 surviving patients developed exocrine insufficiency, and 19 (33%) of 58 without prior diabetes mellitus developed endocrine insufficiency. CONCLUSIONS Almost all patients undergoing necrosectomy developed significant early or late complications or both. Multiorgan failure and postoperative hemorrhage were independent predictors of mortality. Long-term follow-up was important because 62% developed complications, and 16% of those with complications required surgical or endoscopic intervention.
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Affiliation(s)
- S Connor
- Department of Surgery, Royal Liverpool University Hospital
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Connor S, Bosonnet L, Alexakis N, Raraty M, Ghaneh P, Sutton R, Neoptolemos JP. Serum CA19-9 measurement increases the effectiveness of staging laparoscopy in patients with suspected pancreatic malignancy. Dig Surg 2005; 22:80-5. [PMID: 15849467 DOI: 10.1159/000085297] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2004] [Accepted: 11/24/2004] [Indexed: 12/30/2022]
Abstract
BACKGROUND/AIMS Staging laparoscopy for suspected pancreatic neoplasia is not widely accepted due to its low yield. The aim of this study was to determine if serum carbohydrate antigen (CA19-9) levels could be used to improve the selection of patients for staging laparoscopy. METHODS The data from a prospectively collected database (1997-2004) with 159 patients who had computed tomography-predicted resectable disease and who had undergone laparoscopic staging were analysed to determine if a low preoperative CA19-9 level (< or =150 kU/l, or < or =300 kU/l with a bilirubin >35 micromol/l) identified patients in whom laparoscopy was not useful. RESULTS The CA19-9 level was >150 kU/l in 96 patients of whom 75 (78%) were considered resectable following laparoscopic assessment. There were 63 patients with a CA19-9 < or =150 kU/l of whom 60 (95%) were considered resectable following laparoscopic assessment. The sensitivity, specificity, positive predictive value and negative predictive value for CA19-9 < or =150 kU/l in predicting that laparoscopic assessment would judge patients as resectable were 44, 88, 95 and 22%, respectively. A cut-off level of < or =300 kU/l in patients with a bilirubin >35 micromol/l produced values of 30, 94, 94 and 28%, respectively. By using CA19-9 < or =150 kU/l, laparoscopy could have been avoided in 40% of patients, increased to 55% of patients with adjustment for the presence of jaundice; concomitantly, the yield from laparoscopy would have been increased from 15 to 22 and 25%, respectively. CONCLUSION Use of serum CA19-9 levels would increase the efficiency of laparoscopic staging in patients with suspected pancreatic malignancy.
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Affiliation(s)
- S Connor
- Department of Surgery, University of Liverpool, Liverpool, UK
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Lytras D, Connor S, Bosonnet L, Jayan R, Evans J, Hughes M, Garvey CJ, Ghaneh P, Sutton R, Vinjamuri S, Neoptolemos JP. Positron emission tomography does not add to computed tomography for the diagnosis and staging of pancreatic cancer. Dig Surg 2005; 22:55-61; discussion 62. [PMID: 15838173 DOI: 10.1159/000085347] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2004] [Accepted: 09/30/2004] [Indexed: 12/15/2022]
Abstract
BACKGROUND Positron emission tomography (PET) has been proposed for pancreatic cancer diagnosis and staging. METHODS 112 patients with suspected pancreatic cancer underwent 18F-fluoro-2-deoxy-D-glucose gamma camera PET and computed tomography (CT), of whom 62 also had laparoscopic ultrasonography and 70 underwent abdominal exploration for potential resection. The final diagnosis was malignancy in 78 and benign disease in 34 patients (25 with chronic pancreatitis). RESULTS The diagnostic sensitivity and specificity for PET were 73 and 60% compared to 89 and 65% for CT respectively (Cohen's kappa = 0.59). In 30 patients CT was equivocal with cancer in 14 and benign disease in 16. PET correctly diagnosed 13 of these patients (cancer in 6 and benign disease in 7), interpreted 4 as equivocal (cancer in 3 and benign disease in 1) but was incorrect in the remaining 13 patients (cancer in 5 and benign disease in 8). The sensitivity and specificity for detecting small volume metastatic disease were 20 and 94% for CT and 22 and 91% for PET, respectively. CONCLUSION PET had a similar accuracy to that of CT for imaging pancreatic cancer but it did not provide any additional information in patients with equivocal CT findings and currently would seem of little benefit for the staging of pancreatic cancer.
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Affiliation(s)
- D Lytras
- Department of Surgery, University of Liverpool, Liverpool, UK
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Vitone LJ, Greenhalf W, Howes NR, Neoptolemos JP. Hereditary pancreatitis and secondary screening for early pancreatic cancer. Rocz Akad Med Bialymst 2005; 50:73-84. [PMID: 16358943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Hereditary pancreatitis is an autosomal dominant disease with incomplete penetrance (80%), accounting for approximately 1% of all cases of pancreatitis. It is characterized by the onset of recurrent attacks of acute pancreatitis in childhood and frequent progression to chronic pancreatitis. Whitcomb et al. identified the cationic trypsinogen gene (PRSS1) on chromosome 7q35 as the site of the mutation that causes hereditary pancreatitis. The European registry of hereditary pancreatitis and familial pancreatic cancer (EUROPAC) aims to identify and make provisions for those affected by hereditary pancreatitis and familial pancreatic cancer. The most common mutations in hereditary pancreatitis are R122H, N29I and A16V but many families have been described with clinically defined hereditary pancreatitis where there is no PRSS1 mutation. It is known that the cumulative lifetime risk (to age 70 years) of pancreatic cancer is 40% in individuals with hereditary pancreatitis. This subset of individuals form an ideal group for the development of a screening programme aimed at detecting pancreatic cancer at an early stage in an attempt to improve the presently poor long-term survival. Current screening strategies involve multimodality imaging (computed tomography, endoluminal ultrasound) and endoscopic retrograde cholangiopancreatography for pancreatic juice collection followed by molecular analysis of the DNA extracted from the juice. The potential benefit of screening (curative resection) must be balanced against the associated morbidity and mortality of surgery. Philosophically, the individual's best interest must be sought in light of the latest advances in medicine and science following discussions with a multidisciplinary team in specialist pancreatic centres.
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Affiliation(s)
- L J Vitone
- Division of Surgery & Oncology, The University of Liverpool, United Kingdom
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Connor S, Bosonnet L, Ghaneh P, Alexakis N, Hartley M, Campbell F, Sutton R, Neoptolemos JP. Survival of patients with periampullary carcinoma is predicted by lymph node 8a but not by lymph node 16b1 status. Br J Surg 2004; 91:1592-9. [PMID: 15515111 DOI: 10.1002/bjs.4761] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to assess the impact of metastatic disease in lymph nodes 8a and 16b1 (as defined by the Japanese Pancreas Society) on survival in patients with periampullary malignancy. METHODS Patients undergoing resection for primary pancreatic ductal adenocarcinoma or intrapancreatic bile duct adenocarcinoma were identified from a prospective database (September 1997-May 2003). RESULTS Thirteen of 54 and ten of 44 evaluable patients had metastatic involvement of lymph nodes 8a and 16b1 respectively. Metastatic involvement of lymph node 8a was associated with a significantly shorter median survival (197 versus 470 days; P = 0.003) but metastatic involvement of lymph node 16b1 did not affect survival (457 versus 503 days; P = 0.185). Multivariate analysis showed lymph node 8a status to be the strongest predictor of outcome (P = 0.006). Median survival of those with metastatic lymph node 8a was not significantly different from that of 81 patients with overt metastatic periampullary cancer at the time of diagnosis (98 days; P = 0.072) CONCLUSION Lymph node 8a was an independent prognostic factor in patients with periampullary malignancy, but lymph node 16b1 was not. Survival in those with metastatic lymph node 8a was not significantly different from that in patients with metastatic disease at presentation. Preoperative determination of lymph node 8a status may have important implications in selecting patients for treatment.
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Affiliation(s)
- S Connor
- Department of Surgery, University of Liverpool, Royal Liverpool Hospital, Liverpool, UK
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Abstract
Abstract
Background
Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.
Methods
An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.
Results
Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.
Conclusion
The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.
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Affiliation(s)
- N Alexakis
- Department of Surgery, University of Liverpool, Royal Liverpool University Hospital, 5th floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK
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