An Improved Staging System for Locally Advanced Pancreatic Cancer: A Critical Need in the Multidisciplinary Era

Fromer, Marc W.; Hawthorne, Jenci; Philips, Prejesh; Egger, Michael E.; Scoggins, Charles R.; McMasters, Kelly M.; Martin, Robert C.G.

doi:10.1245/s10434-021-10174-z

Cited by 14 publications

(13 citation statements)

References 59 publications

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“…A diagnosis of LAPC disease was established by biopsy proven adenocarcinoma of the pancreas with unreconstructable venous involvement or greater than 180° encasement of their superior mesenteric artery (SMA) or celiac artery without evidence of metastatic lesions ( 12 , 14 , 15 ). Patients were also further sub-classified by our recent Stage III classification sub-types ( 16 ). Patients were further considered for inclusion in the study if the treating physician at the aforementioned participating institutions believed that ablation of their soft tissue would be feasible in the care of their disease, as has been previously described and outlined ( 17 – 19 ).…”

Section: Methodsmentioning

confidence: 99%

Optimizing Patient Selection for Irreversible Electroporation of Locally Advanced Pancreatic Cancer: Analyses of Survival

et al. 2022

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BackgroundIrreversible electroporation (IRE) has emerged as a viable consolidative therapy after induction chemotherapy, in which this combination has improved overall survival of locally advanced pancreatic cancer (LAPC). Optimal timing and patient selection for irreversible electroporation remains a clinically unmet need. The aim of this study was to investigate preoperative factors that may assist in predicting progression-free and overall survival following IRE.MethodsA multi-institutional, prospectively maintained database was reviewed for patients with LAPC treated with induction chemotherapy followed by open-technique irreversible electroporation from 7/2015-5/2019. RECIST 1.1 criteria were used to assess tumor response and radiological progression. Overall survival (OS) and progression-free survival (PFS) were recorded. Survival analyses were performed using Kaplan Meier and Cox multivariable regression analyses.Results187 LAPC patients (median age 62 years range, 21 – 91, 65% men, 35% women) were treated with IRE. Median PFS was 21.7 months and median OS from diagnosis was 25.5 months. On multivariable analysis, age ≤ 61 (HR 0.41, 95%CI 0.21-0.78, p<0.008) and no prior radiation (HR 0.49, 95%CI 0.26-0.94, p=0.03) were positive predictors of OS after IRE. Age ≤ 61(HR 0.53, 95%CI, 0.28-.99, p=0.046) and FOLFIRINOX followed by gemcitabine/abraxane induction chemotherapy (HR 0.37,95%CI 0.15-0.89, p=0.027) predicted prolonged PFS after IRE. Abnormal CA19-9 values at the time of surgery negatively impacted both OS (HR 2.46, 95%CI 1.28-4.72, p<0.007) and PFS (HR 2.192, 95%CI 1.143-4.201, p=0.018) following IRE.ConclusionsAge, CA 19-9 response, avoidance of pre-IRE radiation, and FOLFIRINOX plus gemcitabine/abraxane induction chemotherapy are prominent factors to consider when referring or selecting LAPC patients to undergo IRE.

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Section: Methodsmentioning

confidence: 99%

Optimizing Patient Selection for Irreversible Electroporation of Locally Advanced Pancreatic Cancer: Analyses of Survival

et al. 2022

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“…Before commencing with either FOLFIRINOX or gemcitabine and subsequent IRE, triphasic computed tomography scan with pancreatic protocol (0.7 mm cuts) and three-dimensional reconstruction is performed to appropriately stage the tumor ( 72 ). The presence or absence of superior mesenteric artery or vein or celiac artery encasement, distant metastases or peritoneal spread on imaging will guide the choice of chemotherapy and determine whether an operative approach is possible ( 5 – 11 ). Moreover, diagnostic laparoscopy is performed with paracolic and pelvic washing to detect smaller distant tumor foci that would again signify inoperable disease.…”

Section: Application Of Ire In Conjunction With Chemotherapymentioning

confidence: 99%

“…Although surgical resection is the mainstay treatment with curative intent, only up to 30% of pancreatic cancer cases are amenable to resection ( 2 , 3 ). Hence, according to the extent of vascular involvement and tumor resectability, non-metastatic disease is classified as resectable, borderline resectable, and locally advanced pancreatic cancer (LAPC) ( 4 ), with LAPC having a variable definition depending on the different consensus guidelines ( Table 1 ) ( 5 – 11 ). The standard of care for resectable pancreatic cancer is resection followed by adjuvant chemotherapy, and for borderline pancreatic cancer is neoadjuvant therapy ( 12 ).…”

Section: Introductionmentioning

confidence: 99%

The Synergistic Role of Irreversible Electroporation and Chemotherapy for Locally Advanced Pancreatic Cancer

et al. 2022

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Irreversible electroporation (IRE) is a local ablative technique used in conjunction with chemotherapy to treat locally advanced pancreatic cancer (LAPC). The combination of IRE and chemotherapy has showed increased overall survival when compared to chemotherapy alone, pointing towards a possible facilitating effect of IRE on chemotherapeutic drug action and delivery. This review aims to present current chemotherapeutic regimens for LAPC and their co-implementation with IRE, with an emphasis on possible molecular augmentative mechanisms of drug delivery and action. Moreover, the potentiating mechanism of IRE on immunotherapy, M1 oncolytic virus and dendritic cell (DC)-based treatments is briefly explored. Investigating the synergistic effect of IRE on currently established treatment regimens as well as newer ones, may present exciting new possibilities for future studies seeking to improve current LAPC treatment algorithms.

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“…Patient selection for surgical exploration is based on both tumor biology [ 10 ] and anatomical staging [ 11 , 12 ]. Unfortunately, contrast-enhanced computed tomography (CE-CT) imaging is inaccurate to determine the resectability of LAPC following induction therapy because it cannot differentiate between vital tumor tissue and fibrosis [ 13 ], whereby the sensitivity and specificity on the resectability in patients with PDAC who underwent resection after preoperative chemo(radio)therapy are 45–78% and 60–85%, respectively [ 14 , 15 ].…”

Section: Introductionmentioning

confidence: 99%

Added value of 3T MRI and the MRI-halo sign in assessing resectability of locally advanced pancreatic cancer following induction chemotherapy (IMAGE-MRI): prospective pilot study

Stoop

Veldhuisen²,

Rijssen³

et al. 2022

Langenbecks Arch Surg

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Background Restaging of locally advanced pancreatic cancer (LAPC) after induction chemotherapy using contrast-enhanced computed tomography (CE-CT) imaging is imprecise in evaluating local tumor response. This study explored the value of 3 Tesla (3 T) contrast-enhanced (CE) and diffusion-weighted (DWI) magnetic resonance imaging (MRI) for local tumor restaging. Methods This is a prospective pilot study including 20 consecutive patients with LAPC with RECIST non-progressive disease on CE-CT after induction chemotherapy. Restaging CE-CT, CE-MRI, and DWI-MRI were retrospectively evaluated by two abdominal radiologists in consensus, scoring tumor size and vascular involvement. A halo sign was defined as replacement of solid perivascular (arterial and venous) tumor tissue by a zone of fatty-like signal intensity. Results Adequate MRI was obtained in 19 patients with LAPC after induction chemotherapy. Tumor diameter was non-significantly smaller on CE-MRI compared to CE-CT (26 mm vs. 30 mm; p = 0.073). An MRI-halo sign was seen on CE-MRI in 52.6% (n = 10/19), whereas a CT-halo sign was seen in 10.5% (n = 2/19) of patients (p = 0.016). An MRI-halo sign was not associated with resection rate (60.0% vs. 62.5%; p = 1.000). In the resection cohort, patients with an MRI-halo sign had a non-significant increased R0 resection rate as compared to patients without an MRI-halo sign (66.7% vs. 20.0%; p = 0.242). Positive and negative predictive values of the CE-MRI-halo sign for R0 resection were 66.7% and 66.7%, respectively. Conclusions 3 T CE-MRI and the MRI-halo sign might be helpful to assess the effect of induction chemotherapy in patients with LAPC, but its diagnostic accuracy has to be evaluated in larger series.

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An Improved Staging System for Locally Advanced Pancreatic Cancer: A Critical Need in the Multidisciplinary Era

Cited by 14 publications

References 59 publications

Optimizing Patient Selection for Irreversible Electroporation of Locally Advanced Pancreatic Cancer: Analyses of Survival

Optimizing Patient Selection for Irreversible Electroporation of Locally Advanced Pancreatic Cancer: Analyses of Survival

The Synergistic Role of Irreversible Electroporation and Chemotherapy for Locally Advanced Pancreatic Cancer

Added value of 3T MRI and the MRI-halo sign in assessing resectability of locally advanced pancreatic cancer following induction chemotherapy (IMAGE-MRI): prospective pilot study

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