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Barreto SG, Shrikhande SV, Sirohi B. Neoadjuvant Therapy in Borderline Resectable Pancreatic Cancer. Indian J Surg Oncol 2024; 15:249-254. [PMID: 38817993 PMCID: PMC11133292 DOI: 10.1007/s13193-021-01361-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/31/2021] [Indexed: 12/09/2022] Open
Abstract
In this perspective, we present our assessment of all of the known accumulated evidence on the role of neoadjuvant therapy in the management of borderline resectable pancreatic cancer highlighting the gaps in the data, the current regimens used and providing a brief insight into the way forward.
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Affiliation(s)
- Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia Australia
| | - Shailesh V. Shrikhande
- GI and HPB Services, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra India
| | - Bhawna Sirohi
- Department of Medical Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu India
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Khasawneh H, Ferreira Dalla Pria HR, Miranda J, Nevin R, Chhabra S, Hamdan D, Chakraborty J, Biachi de Castria T, Horvat N. CT Imaging Assessment of Pancreatic Adenocarcinoma Resectability after Neoadjuvant Therapy: Current Status and Perspective on the Use of Radiomics. J Clin Med 2023; 12:6821. [PMID: 37959287 PMCID: PMC10649102 DOI: 10.3390/jcm12216821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
Pancreatic adenocarcinoma (PDAC) is the most common pancreatic cancer and is associated with poor prognosis, a high mortality rate, and a substantial number of healthy life years lost. Surgical resection is the primary treatment option for patients with resectable disease; however, only 10-20% of all patients with PDAC are eligible for resection at the time of diagnosis. In this context, neoadjuvant therapy has the potential to increase the number of patients who are eligible for resection, thereby improving the overall survival rate. For patients who undergo neoadjuvant therapy, computed tomography (CT) remains the primary imaging tool for assessing treatment response. Nevertheless, the interpretation of imaging findings in this context remains challenging, given the similarity between viable tumor and treatment-related changes following neoadjuvant therapy. In this review, following an overview of the various treatment options for PDAC according to its resectability status, we will describe the key challenges regarding CT-based evaluation of PDAC treatment response following neoadjuvant therapy, as well as summarize the literature on CT-based evaluation of PDAC treatment response, including the use of radiomics. Finally, we will outline key recommendations for the management of PDAC after neoadjuvant therapy, taking into consideration CT-based findings.
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Affiliation(s)
- Hala Khasawneh
- Department of Radiology, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390, USA;
| | | | - Joao Miranda
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.M.); (R.N.); (S.C.)
- Department of Radiology, University of Sao Paulo, R. Dr. Ovidio Pires de Campos, 75-Cerqueira Cesar, Sao Paulo 05403-010, SP, Brazil
| | - Rachel Nevin
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.M.); (R.N.); (S.C.)
| | - Shalini Chhabra
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.M.); (R.N.); (S.C.)
| | - Dina Hamdan
- Department of Radiology, The Mount Sinai Hospital, 1468 Madison Ave, New York, NY 10029, USA;
| | - Jayasree Chakraborty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA;
| | - Tiago Biachi de Castria
- Department of Gastrointestinal Oncology, Moffit Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
- Morsani College of Medicine, University of South Florida, 4202 E. Fowler Avenue, Tampa, FL 33620, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; (J.M.); (R.N.); (S.C.)
- Department of Radiology, University of Sao Paulo, R. Dr. Ovidio Pires de Campos, 75-Cerqueira Cesar, Sao Paulo 05403-010, SP, Brazil
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Lee DH, Ha HI, Jang JY, Lee JW, Choi JY, Bang S, Lee CH, Kim WB, Lee SS, Kim SC, Kang BK, Lee JM. High-resolution pancreatic computed tomography for assessing pancreatic ductal adenocarcinoma resectability: a multicenter prospective study. Eur Radiol 2023; 33:5965-5975. [PMID: 36988715 DOI: 10.1007/s00330-023-09584-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE This prospective multicenter study aimed to evaluate the diagnostic performance of 80-kVp thin-section pancreatic CT in determining pancreatic ductal adenocarcinoma (PDAC) resectability according to the recent National Comprehensive Cancer Network (NCCN) guidelines. METHODS We prospectively enrolled surgical resection candidates for PDAC from six tertiary referral hospitals (study identifier: NCT03895177). All participants underwent pancreatic CT using 80 kVp tube voltage with 1-mm reconstruction interval. The local resectability was prospectively evaluated using NCCN guidelines at each center and classified into three categories: resectable, borderline resectable, and unresectable. RESULTS A total of 138 patients were enrolled; among them, 60 patients underwent neoadjuvant therapy. R0 resection was achieved in 103 patients (74.6%). The R0 resection rates were 88.7% (47/53), 52.4% (11/21), and 0.0% (0/4) for resectable, borderline resectable, and unresectable disease, respectively, in 78 patients who underwent upfront surgery. Meanwhile, the rates were 90.9% (20/22), 76.7% (23/30), and 25.0% (2/8) for resectable, borderline resectable, and unresectable PDAC, respectively, in patients who received neoadjuvant therapy. The area under curve of high-resolution CT in predicting R0 resection was 0.784, with sensitivity, specificity, and accuracy of 87.4% (90/103), 48.6% (17/35), and 77.5% (107/138), respectively. Tumor response was significantly associated with the R0 resection after neoadjuvant therapy (odds ratio [OR] = 38.99, p = 0.016). CONCLUSION An 80-kVp thin-section pancreatic CT has excellent diagnostic performance in assessing PDAC resectability, enabling R0 resection rates of 88.7% and 90.9% for patients with resectable PDAC who underwent upfront surgery and patients with resectable PDAC after neoadjuvant therapy, respectively. KEY POINTS • The margin-negative (R0) resection rates were 88.7% (47/53), 52.4% (11/21), and 0.0% (0/4) for resectable, borderline resectable, and unresectable pancreatic ductal adenocarcinoma (PDAC), respectively, on 80-kVp thin-section pancreatic CT in the 78 patients who underwent upfront surgery. • Among the 60 patients who underwent neoadjuvant therapy, the R0 rates were 90.9% (20/22), 76.7% (23/30), and 25.0% (2/8) for resectable, borderline resectable, and unresectable PDAC, respectively. • Tumor response, along with the resectability status on pancreatic CT, was significantly associated with the R0 resection rate after neoadjuvant therapy.
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Affiliation(s)
- Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea
| | - Hong Il Ha
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Woo Lee
- Department of Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jin-Young Choi
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Hee Lee
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Wan Bae Kim
- Division of Hepato-Biliary-Pancreatic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Song Cheol Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo-Kyeong Kang
- Department of Radiology, Hanyang University College of Medicine, Seoul, Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.
- Department of Radiology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea.
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Guggenberger KV, Bley TA, Held S, Keller R, Flemming S, Wiegering A, Germer CT, Kimmel B, Kunzmann V, Hartlapp I, Anger F. Predictive value of computed tomography on surgical resectability in locally advanced pancreatic cancer treated with multiagent induction chemotherapy: Results from a prospective, multicentre phase 2 trial (NEOLAP-AIO-PAK-0113). Eur J Radiol 2023; 163:110834. [PMID: 37080059 DOI: 10.1016/j.ejrad.2023.110834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/05/2023] [Accepted: 04/07/2023] [Indexed: 04/22/2023]
Abstract
PURPOSE To assess the role of current imaging-based resectability criteria and the degree of radiological downsizing in locally advanced pancreatic adenocarcinoma (LAPC) after multiagent induction chemotherapy (ICT) in multicentre, open-label, randomized phase 2 trial. METHOD LAPC patients were prospectively treated with multiagent ICT followed by surgical exploration within the NEOLAP trial. All patients underwent CT scan at baseline and after ICT to assess resectability status according to national comprehensive cancer network guidelines (NCCN) criteria and response evaluation criteria in solid tumors (RECIST) at the local study center and retrospectively in a central review. Imaging results were compared in terms of local and central staging, downsizing and pathological resection status. RESULTS 83 patients were evaluable for central review of baseline and restaging imaging results. Downstaging by central review was rarely seen after multiagent ICT (7.7%), whereas tumor downsizing was documented frequently (any downsizing 90.4%, downsizing to partial response (PR) according to RECIST: 26.5%). Patients with any downsizing showed no significant different R0 resection rate (37.3%) as patients that fulfilled the criteria of PR (40.9%). The sensitivity of any downsizing for predicting R0 resection was 97% with a negative predictive value (NPV) of 0.88. ROC-analysis revealed that tumor downsizing was a predictor of R0 resection (AUC 0.647, p = 0.028) with a best cut-off value of 22.5% downsizing yielding a sensitivity of 65% and a specificity of 61%. CONCLUSIONS Imaging-based tumor downsizing and not downstaging can guide the selection of patients with a realistic chance of R0-resection in LAPC after multi-agent ICT.
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Affiliation(s)
- K V Guggenberger
- Department of Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - T A Bley
- Department of Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - S Held
- Department of Biometrics, ClinAssess GmbH, Leverkusen, Germany
| | - R Keller
- Clinical Research, AIO Studien gGmbH, Berlin, Germany
| | - S Flemming
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - A Wiegering
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - C T Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - B Kimmel
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - V Kunzmann
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - I Hartlapp
- Department of Internal Medicine II, Medical Oncology and Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, Würzburg, Germany
| | - F Anger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
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Karunakaran M, Barreto SG. Surgery for pancreatic cancer: current controversies and challenges. Future Oncol 2021; 17:5135-5162. [PMID: 34747183 DOI: 10.2217/fon-2021-0533] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.
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Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta-The Medicity, Gurugram 122001, India.,Department of Liver Transplantation & Regenerative Medicine, Medanta-The Medicity, Gurugram 122001, India
| | - Savio George Barreto
- College of Medicine & Public Health, Flinders University, South Australia, Australia.,Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia
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Park SJ, Kim JH, Joo I, Han JK. Predictors of conversion surgery in patients with pancreatic cancer who underwent neoadjuvant or palliative FOLFIRINOX treatment using baseline and follow-up CT. Abdom Radiol (NY) 2021; 46:4765-4778. [PMID: 34085090 DOI: 10.1007/s00261-021-03127-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/11/2021] [Accepted: 05/19/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE We aimed to evaluate the predictive factors of conversion surgery in pancreatic adenocarcinoma (PAC) after neoadjuvant or palliative FOLFIRINOX using baseline and follow-up CT. METHODS We retrospectively included 189 patients who had undergone more than 4 cycles of FOLFIRINOX. We reviewed baseline CT (B-CT), 1st follow-up CT (1st-CT), and the preoperative or last follow-up CT (L-CT) and determined tumor size changes according to the Response Evaluation Criteria in Solid Tumors (RECIST 1.1). Extra-pancreatic perineural invasion (EPNI) and resectability using NCCN 2019 guideline were evaluated. Subgroup analysis by baseline resectability was performed. RESULTS B-CT included resectable (n = 25, 23.2%), borderline (n = 55, 29.1%), locally advanced (n = 44, 23.3%), and metastatic (n = 65, 34.4%) PAC. Seventy-four patients had undergone surgery (39.2%) with an 83.8% (62/74) R0 resection. For operability, resectable status at L-CT (hazard ratio (HR) 65.5; 95% confidence interval (CI) 5.0-865; P = 0.002), RECIST (partial response) at 1st-CT (HR 3.6; 95% CI 1.1-11.7; P = 0.032), and baseline borderline resectability (HR 8.6; 95% CI 1.6-46.4; P = 0.013) were important predictors. Based on a size reduction cut-off of 22.2%, the area under the receiver operating characteristic (ROC) curve (Az) was 0.761 (sensitivity = 70.3%, specificity = 74.8%). In subgroup analysis, RECIST (partial response) at 1st-CT was a significant predictor of locally advanced PAC (HR 32; 95% CI 4.5-227, P 0.001), and the optimal cut-off was 22.2% (Az = 0.914; sensitivity = 100%, specificity = 75%). Baseline tumor size ([Formula: see text] 4 cm) (HR 5.6, 95% CI 1.3-24.3, P = 0.022) and unresectable status at 1st-CT (HR 4.8, 95% CI 1.1-20.6, P = 0.035) were significantly associated with margin-positive resection. CONCLUSION Both baseline and follow-up CT findings are useful to predict conversion surgery for PAC after FOLFIRINOX.
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Affiliation(s)
- Sae-Jin Park
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
- Department of Radiology, SMG-SNU Boramae Medical Cencer, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea.
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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Pancreatic Ductal Adenocarcinoma: Relating Biomechanics and Prognosis. J Clin Med 2021; 10:jcm10122711. [PMID: 34205335 PMCID: PMC8234178 DOI: 10.3390/jcm10122711] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/12/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most common form of pancreatic cancer and carries a dismal prognosis. Resectable patients are treated predominantly with surgery while borderline resectable patients may receive neoadjuvant treatment (NAT) to downstage their disease prior to possible resection. PDAC tissue is stiffer than healthy pancreas, and tissue stiffness is associated with cancer progression. Another feature of PDAC is increased tissue heterogeneity. We postulate that tumour stiffness and heterogeneity may be used alongside currently employed diagnostics to better predict prognosis and response to treatment. In this review we summarise the biomechanical changes observed in PDAC, explore the factors behind these changes and describe the clinical consequences. We identify methods available for assessing PDAC biomechanics ex vivo and in vivo, outlining the relative merits of each. Finally, we discuss the potential use of radiological imaging for prognostic use.
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Zhang Y, Huang ZX, Song B. Role of imaging in evaluating the response after neoadjuvant treatment for pancreatic ductal adenocarcinoma. World J Gastroenterol 2021; 27:3037-3049. [PMID: 34168406 PMCID: PMC8192284 DOI: 10.3748/wjg.v27.i22.3037] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/08/2021] [Accepted: 04/26/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive malignancy. Despite the development of multimodality treatments, including surgical resection, radiotherapy, and chemotherapy, the long-term prognosis of patients with PDAC remains poor. Recently, the introduction of neoadjuvant treatment (NAT) has made more patients amenable to surgery, increasing the possibility of R0 resection, treatment of occult micro-metastasis, and prolongation of overall survival. Imaging plays a vital role in tumor response evaluation after NAT. However, conventional imaging modalities such as multidetector computed tomography have limited roles in the assessment of tumor resectability after NAT for PDAC because of the similar appearance of tissue fibrosis and tumor infiltration. Perfusion computed tomography, using blood perfusion as a biomarker, provides added value in predicting the histopathologic response of PDAC to NAT by reflecting the changes in tumor matrix and fibrosis content. Other imaging technologies, including diffusion-weighted imaging of magnetic resonance imaging and positron emission tomography, can reveal the tumor response by monitoring the structural changes in tumor cells and functional metabolic changes in tumors after NAT. In addition, with the renewed interest in data acquisition and analysis, texture analysis and radiomics have shown potential for the early evaluation of the response to NAT, thus improving patient stratification to achieve accurate and intensive treatment. In this review, we briefly introduce the application and value of NAT in resectable and unresectable PDAC. We also summarize the role of imaging in evaluating the response to NAT for PDAC, as well as the advantages, limitations, and future development directions of current imaging techniques.
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Affiliation(s)
- Yun Zhang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zi-Xing Huang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bin Song
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Shrikhande SV, Barreto S, Sirohi B, Bal M, Shrimali RK, Chacko RT, Chaudhari V, Bhatia V, Kulkarni S, Kaur T, Dhaliwal RS, Rath GK. Indian council of medical research consensus document for the management of pancreatic cancer. Indian J Med Paediatr Oncol 2021. [DOI: 10.4103/ijmpo.ijmpo_29_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
| | | | | | - Munita Bal
- Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Raj Kumar Shrimali
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Raju T Chacko
- Department of Medical Oncology, Division of Non-Communicable Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Vikram Bhatia
- Department of Radiation Oncology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Tanvir Kaur
- Department of Gatroenterology, Indian Council of Medical Research, New Delhi, India
| | - R S Dhaliwal
- Department of Gatroenterology, Indian Council of Medical Research, New Delhi, India
| | - Goura Kishor Rath
- Department of Gatroenterology, Indian Council of Medical Research, New Delhi, India
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Wei K, Hackert T. Surgical Treatment of Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2021; 13:cancers13081971. [PMID: 33923884 PMCID: PMC8074119 DOI: 10.3390/cancers13081971] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Surgery is the only potential cure for pancreatic ductal adenocarcinoma and should always be combined with adjuvant chemotherapy or other multimodal treatment. Besides the advances in such multimodal approaches, there has been substantial progress in surgical techniques to especially address advanced resections. These techniques include specific operative steps, such as ‘artery first’ or ‘uncinate first’ approaches as well as techniques that allow safe vascular resection and reconstruction to achieve radical tumor removal. Most recently, also minimally-invasive and robotic approaches have been adopted for pancreatic cancer surgery; however, there is no high-level evidence on these evolving techniques especially with regards to long-term results compared to conventional surgical techniques. Abstract Pancreatic ductal adenocarcinoma (PDAC) represents an aggressive tumor of the digestive system with still low five-year survival of less than 10%. Although there are improvements for multimodal therapy of PDAC, surgery still remains the effective way to treat the disease. Combined with adjuvant and/or neoadjuvant treatment, pancreatic surgery is able to enhance the five-year survival up to around 20%. However, pancreatic resection is always associated with a high risk of complications and regarded as one of the most complex fields in abdominal surgery. This review gives a summary on the surgical treatment for PDAC based on the current literature with a special focus on resection techniques.
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Abstract
Pancreatic ductal adenocarcinoma (PDAC) represents an aggressive tumor of the digestive system with still low five-year survival of less than 10%. Although there are improvements for multimodal therapy of PDAC, surgery still remains the effective way to treat the disease. Combined with adjuvant and/or neoadjuvant treatment, pancreatic surgery is able to enhance the five-year survival up to around 20%. However, pancreatic resection is always associated with a high risk of complications and regarded as one of the most complex fields in abdominal surgery. This review gives a summary on the surgical treatment for PDAC based on the current literature with a special focus on resection techniques.
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Park SJ, Jang S, Han JK, Kim H, Kwon W, Jang JY, Lee KB, Kim H, Lee DH. Preoperative assessment of the resectability of pancreatic ductal adenocarcinoma on CT according to the NCCN Guidelines focusing on SMA/SMV branch invasion. Eur Radiol 2021; 31:6889-6897. [PMID: 33740095 DOI: 10.1007/s00330-021-07847-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/15/2021] [Accepted: 02/26/2021] [Indexed: 02/23/2023]
Abstract
OBJECTIVES For patients with pancreatic adenocarcinoma (PAC), adequate determination of disease extent is critical for optimal management. We aimed to evaluate diagnostic accuracy of CT in determining the resectability of PAC based on 2020 NCCN Guidelines. METHODS We retrospectively enrolled 368 consecutive patients who underwent upfront surgery for PAC and preoperative pancreas protocol CT from January 2012 to December 2017. The resectability of PAC was assessed based on 2020 NCCN Guidelines and compared to 2017 NCCN Guidelines using chi-square tests. Overall survival (OS) was estimated using the Kaplan-Meier method and compared using log-rank test. R0 resection-associated factors were identified using logistic regression analysis. RESULTS R0 rates were 80.8% (189/234), 67% (71/106), and 10.7% (3/28) for resectable, borderline resectable, and unresectable PAC according to 2020 NCCN Guidelines, respectively (p < 0.001). The estimated 3-year OS was 28.9% for borderline resectable PAC, which was significantly lower than for resectable PAC (43.6%) (p = 0.004) but significantly higher than for unresectable PAC (0.0%) (p < 0.001). R0 rate was significantly lower in patients with unresectable PAC according to 2020 NCCN Guidelines (10.7%, 3/28) than in those with unresectable PAC according to the previous version (31.7%, 20/63) (p = 0.038). In resectable PAC, tumor size ≥ 3 cm (p = 0.03) and abutment to portal vein (PV) (p = 0.04) were independently associated with margin-positive resection. CONCLUSIONS The current NCCN Guidelines are useful for stratifying patients according to prognosis and perform better in R0 prediction in unresectable PAC than the previous version. Larger tumor size and abutment to PV were associated with margin-positive resection in patients with resectable PAC. KEY POINTS • The updated 2020 NCCN Guidelines were useful for stratifying patients according to prognosis. • The updated 2020 NCCN Guidelines performed better in the prediction of margin-positive resection in unresectable cases than the previous version. • Tumor size ≥ 3 cm and abutment to the portal vein were associated with margin-positive resection in patients with resectable pancreatic adenocarcinoma.
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Affiliation(s)
- Sae-Jin Park
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea.,Department of Radiology, SMG - SNU Boramae Medical Center, Seoul, South Korea
| | - Siwon Jang
- Department of Radiology, SMG - SNU Boramae Medical Center, Seoul, South Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Wooil Kwon
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Kyoung-Bun Lee
- Department of Pathology, Seoul National University Hospital, Seoul, South Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, Seoul, South Korea
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea. .,Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea.
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13
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Lindemann J, du Toit L, Kotze U, Bernon M, Krige J, Jonas E. Survival equivalence in patients treated for borderline resectable and unresectable locally advanced pancreatic ductal adenocarcinoma: a systematic review and network meta-analysis. HPB (Oxford) 2021; 23:173-186. [PMID: 33268268 DOI: 10.1016/j.hpb.2020.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical relevance of subdivision of non-metastatic pancreatic ductal adenocarcinoma (PDAC) into locally advanced borderline resectable (LA-BR) and locally advanced unresectable (LA-UR) has been questioned. We assessed equivalence of overall survival (OS) in patients with LA-BR and LA-UR PDAC. METHODS A systematic review was performed of studies published January 1, 2009 to August 21, 2019, reporting OS for LA-BR and LA-UR patients treated with or without neoadjuvant therapy (NAT), with or without surgical resection. A frequentist network meta-analysis was used to assess the primary outcome (hazard ratio for OS) and secondary outcomes (OS in LA-BR, LA-UR, and upfront resectable (UFR) PDAC). RESULTS Thirty-nine studies, comprising 14,065 patients in a network of eight unique treatment subgroups were analysed. Overall survival was better for LA-BR than LA-UR patients following surgery both with and without NAT. Neoadjuvant therapy prior to surgery was associated with longer OS for UFR, LA-BR, and LA-UR tumours, compared to upfront surgery. CONCLUSION Survival between the LA-BR and LA-UR subgroups was not equivalent. This subdivision is useful for prognostication, but likely unhelpful in treatment decision making. Our data supports NAT regardless of initial disease extent. Individual patient data assessment is needed to accurately estimate the benefit of NAT.
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Affiliation(s)
- Jessica Lindemann
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa; Department of Surgery, Washington University School of Medicine, 660 South Euclid Ave, Saint Louis, MO, 63110, USA
| | - Leon du Toit
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Urda Kotze
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Marc Bernon
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Jake Krige
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Eduard Jonas
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
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Barreto SG. Pancreatic cancer in Australia: is not it time we address the inequitable resource problem? Future Oncol 2020; 16:1385-1392. [PMID: 32412798 DOI: 10.2217/fon-2020-0109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The present study reviewed the geographical variations in the delivery of pancreatic cancer therapy and whether this impacts overall survival. The evidence suggests a difference in the accessibility of pancreatic cancer care to patients in rural as compared with urban Australia. While centralization of pancreatic surgery is essential to deliver high quality care to patients, it may be interfering with the ease of access of this form of care to patients in regional areas. Access to chemotherapy in regional Australia is also limited. There is need for a concerted effort to improve the overall care and uptake of medical services to patients in metropolitan and remote Australia with the overarching aim of improving survival and meaningful quality of life.
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Affiliation(s)
- Savio George Barreto
- Division of Surgery & Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia.,College of Medicine & Public Health, Flinders University, South Australia, Australia
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15
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Barreto SG, Loveday B, Windsor JA, Pandanaboyana S. Detecting tumour response and predicting resectability after neoadjuvant therapy for borderline resectable and locally advanced pancreatic cancer. ANZ J Surg 2019; 89:481-487. [PMID: 30117669 DOI: 10.1111/ans.14764] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/27/2018] [Accepted: 06/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND This systematic review aimed to determine the accuracy of imaging modalities to predict resectability and R0 resection for borderline resectable (BRPC) or locally advanced pancreatic cancer (LAPC) after neoadjuvant therapy (NAT). METHODS A systematic search of major databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Fifteen studies identified 995 patients of which 683 had BRPC and 312 LAPC. Computed tomography (CT) scan was the most common modality for re-staging (n = 14), followed by positron emission tomography (PET)-CT (n = 3) and endosonography (EUS) (n = 2). Stable disease on RECIST criteria was found in 67% of patients (range 53-80%) with 20% demonstrating reduction in tumour size. A total of 60% of patients underwent surgery post-NAT (range 31-85%) with a R0 rate of 88% (range 57-100%). Accuracy for predicting R0 resectability and T-stage on CT scan was 71 and 49%. A reduction in SUVmax on PET-CT and reduction of tumour stiffness on EUS elastography positively correlated with resectability. CONCLUSIONS More than half the patients undergo resection post-NAT for LAPC and BRPC. Stable, or reduction of, tumour disease may predict resectability. Reduction in tumour SUVmax on PET-CT and decreased tumour stiffness on EUS elastography may be potential markers of NAT response and resectability.
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Affiliation(s)
- Savio G Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Benjamin Loveday
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Hepatobiliary and Pancreatic Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - John A Windsor
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Hepatobiliary and Pancreatic Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Hepatobiliary and Pancreatic Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
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16
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Is it time to reconsider the principles of pancreatic cancer surgery? Pancreatology 2019; 19:204-205. [PMID: 30553775 DOI: 10.1016/j.pan.2018.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 12/11/2022]
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