Is there a role for surgical resection in patients with pancreatic cancer with liver metastases responding to chemotherapy?

Crippa, Stefano; Bittoni, Alessandro; Sebastiani, Elisa; Partelli, Stefano; Zanon, Silvia; Lanese, Andrea; Andrikou, Kalliopi; Muffatti, Francesca; Balzano, Gianpaolo; Reni, Michele; Cascinu, Stefano; Falconi, Massimo

doi:10.1016/j.ejso.2016.06.398

Cited by 118 publications

(151 citation statements)

References 18 publications

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“…While older retrospective studies suggested no benefit from surgical resection to the primary tumor and synchronous liver metastases[26,27], more recent retrospective studies suggested that primary tumor resection following favorable response to systemic chemotherapy in stage IV patients may be considered in highly selected patients[28,29]. However, the number of patients in all these studies was not large enough to derive clear recommendations.…”

Section: Discussionmentioning

confidence: 99%

Prognostic value of site-specific metastases in pancreatic adenocarcinoma: A Surveillance Epidemiology and End Results database analysis

Oweira

Petrausch

Helbling

et al. 2017

WJG

152

109

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AIMTo evaluate the prognostic value of site-specific metastases among patients with metastatic pancreatic carcinoma registered within the Surveillance, Epidemiology and End Results (SEER) database.METHODSSEER database (2010-2013) has been queried through SEER*Stat program to determine the presentation, treatment outcomes and prognostic outcomes of metastatic pancreatic adenocarcinoma according to the site of metastasis. In this study, metastatic pancreatic adenocarcinoma patients were classified according to the site of metastases (liver, lung, bone, brain and distant lymph nodes). We utilized chi-square test to compare the clinicopathological characteristics among different sites of metastases. We used Kaplan-Meier analysis and log-rank testing for survival comparisons. We employed Cox proportional model to perform multivariate analyses of the patient population; and accordingly hazard ratios with corresponding 95%CI were generated. Statistical significance was considered if a two-tailed P value < 0.05 was achieved.RESULTSA total of 13233 patients with stage IV pancreatic cancer and known sites of distant metastases were identified in the period from 2010-2013 and they were included into the current analysis. Patients with isolated distant nodal involvement or lung metastases have better overall and pancreatic cancer-specific survival compared to patients with isolated liver metastases (for overall survival: lung vs liver metastases: P < 0.0001; distant nodal vs liver metastases: P < 0.0001) (for pancreatic cancer-specific survival: lung vs liver metastases: P < 0.0001; distant nodal vs liver metastases: P < 0.0001). Multivariate analysis revealed that age < 65 years, white race, being married, female gender; surgery to the primary tumor and surgery to the metastatic disease were associated with better overall survival and pancreatic cancer-specific survival.CONCLUSIONPancreatic adenocarcinoma patients with isolated liver metastases have worse outcomes compared to patients with isolated lung or distant nodal metastases. Further research is needed to identify the highly selected subset of patients who may benefit from local treatment of the primary tumor and/or metastatic disease.

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Section: Discussionmentioning

confidence: 99%

Prognostic value of site-specific metastases in pancreatic adenocarcinoma: A Surveillance Epidemiology and End Results database analysis

Oweira

Petrausch

Helbling

et al. 2017

WJG

152

109

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“…Metastatic disease is therefore conceived as a palliative condition, without clinical benefit from resectional surgery[58]. However, in a recent report from Milan[99], 127 patients with metastatic PDAC were treated by the new chemotherapeutic regimens, and 11 patients with radiological and biochemical response (Ca19-9 normalization) underwent resection of the pancreatic primary tumor plus liver or lung metastases. Postoperative median survival was 39 mo vs 12 mo for the 116 patients without surgical resection.…”

Section: Resultsmentioning

confidence: 99%

Updated therapeutic outcome for patients with periampullary and pancreatic cancer related to recent translational research

Buanes¹

2016

WJG

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Chemotherapy with improved effect in patients with metastatic pancreatic cancer has recently been established, launching a new era for patients with this very aggressive disease. FOLFIRINOX and gemcitabine plus nab-paclitaxel are different regimens, both capable of stabilizing the disease, thus increasing the number of patients who can reach second line and even third line of treatment. Concurrently, new windows of opportunity open for nutritional support and other therapeutic interventions, improving quality of life. Also pancreatic surgery has changed significantly during the latest years. Extended operations, including vascular/multivisceral resections are frequently performed in specialized centers, pushing borders of resectability. Potentially curative treatment including neoadjuvant and adjuvant chemotherapy is offered new patient groups. Translational research is the basis for the essential understanding of the ongoing development. Even thou biomarkers for clinical management of patients with periampullary tumors have almost been lacking, biomarker driven trials are now in progress. New insight is constantly made available for clinicians; one recent example is selection of patients for gemcitabine treatment based on the expression level of the human equilibrium nucleoside transporter 1. An example of new diagnostic tools is identification of early pancreatic cancer patients by a three-biomarker panel in urine: The proteins lymphatic vessel endothelial hyaluronan receptor 1, regenerating gene 1 alpha and translation elongation factor 1 alpha. Requirement of treatment guideline revisions is intensifying, as combined chemotherapy regimens result in unexpected advantages. The European Study Group for Pancreatic Cancer 4 trial outcome is an illustration: Addition of capecitabine in the adjuvant setting improved overall survival more than expected from the effect in advanced disease. Rapid implementation of new treatment options is mandatory when progress finally extends to patients with this serious disease.

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“…However, in a recent report 128 patients, undergoing resection of the primary tumor and metastases, OS 12.3 mo and 10% five year survival was obtained[34]. In another prospective study 11 patients obtained median OS 39 mo after resection of the pancreatic tumor and metastases[35]. Recent evidence also suggest that patients with only pulmonary metastases is a subgroup with better prognosis[36], and selected M1 patients seem to benefit from surgical resection.…”

Section: Metastatic Diseasementioning

confidence: 99%

Role of surgery in pancreatic cancer

Buanes

2017

WJG

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Treatment of pancreatic cancer is multimodal and surgery is an essential part, mandatory for curative potential. Also chemotherapy is essential, and serious postoperative complications or rapid disease progression may preclude completion of multimodal treatment. The sequence of treatment interventions has therefore become an important concern, and numerous ongoing randomized controlled trials compare clinical outcome after upfront surgery and neoadjuvant treatment with subsequent resection. In previous years, borderline resectable and locally advanced pancreatic cancer was most often considered unresectable. More effective chemotherapy together with the latest improvements in surgical expertise has resulted in extended operations, pushing the borders of resectability. Multivisceral resections with or without resection of major mesenteric vessels are now performed in numerous patients, resulting in better outcome, recorded as overall survival and/or patient reported outcome. But postoperative morbidity increases concurrently, and clinical benefit must be carefully evaluated against risk of potential harm, associated with new comprehensive multimodal treatment sequences. Even though cost/utility analyses are deficient, extended surgery has resulted in significantly longer and better life for many patients with no other treatment alternative. Improved selection of patients to surgery and/or chemotherapy will in the near future be possible, based on better tumor biology insight. Clinically available biomarkers enabling personalized treatment are forthcoming, but these options are still limited. The importance of surgical resection for each patient’s prognosis is presently increasing, justifying sustained expansion of the surgical treatment modality.

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Is there a role for surgical resection in patients with pancreatic cancer with liver metastases responding to chemotherapy?

Cited by 118 publications

References 18 publications

Prognostic value of site-specific metastases in pancreatic adenocarcinoma: A Surveillance Epidemiology and End Results database analysis

Prognostic value of site-specific metastases in pancreatic adenocarcinoma: A Surveillance Epidemiology and End Results database analysis

Updated therapeutic outcome for patients with periampullary and pancreatic cancer related to recent translational research

Role of surgery in pancreatic cancer

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