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Medical oncology and pancreatic cancer: what the radiologist needs to know

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Abstract

The majority of PCs present as advanced disease, and treatment goals are for prolongation of life and palliation of the symptoms. Oncologists rely on our radiology colleagues to provide information on the extent of disease and the effectiveness of our treatment. The stakes rise in those patients where the disease has seemingly not spread and who might be treated with a goal of cure. For this subset of patients, medical oncologists and surgeons require as precise a radiologic description as possible in order to most accurately characterize the extent of the disease, in turn informing us as to the likelihood of a successful surgery and potential cure. In this paper, we review the fine points of imaging that distinguish resectable from borderline or unresectable patients, explain the principles of neoadjuvant and adjuvant therapy for pancreatic cancer, highlight some of the novel therapies now being pioneered in pancreatic cancer, and review radiologic features important for palliative care in patients with these tumors.

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References

  1. Siegel RL, Miller KD, Jemal A (2017) Cancer statistics, 2017. CA Cancer J Clin 67(1):7–30

    Article  PubMed  Google Scholar 

  2. Rahib L, Smith BD, Aizenberg R, et al. (2014) Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res 74(11):2913–2921

    Article  CAS  PubMed  Google Scholar 

  3. Oettle H, Neuhaus P, Hochhaus A, et al. (2013) Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial. JAMA 310(14):1473–1481

    Article  CAS  PubMed  Google Scholar 

  4. Millikan KW, Deziel DJ, Silverstein JC, et al. (1999) Prognostic factors associated with resectable adenocarcinoma of the head of the pancreas. Am Surg. 65(7): 618–623; discussion 623–624.

  5. Neoptolemos JP, Stocken DD, Dunn JA, et al. (2001) Influence of resection margins on survival for patients with pancreatic cancer treated by adjuvant chemoradiation and/or chemotherapy in the ESPAC-1 randomized controlled trial. Ann Surg 234(6):758–768

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Sohn TA, Yeo CJ, Cameron JL, et al. (2000) Resected adenocarcinoma of the pancreas-616 patients: results, outcomes, and prognostic indicators. J Gastrointest Surg 4(6):567–579

    Article  CAS  PubMed  Google Scholar 

  7. Takai S, Satoi S, Toyokawa H, et al. (2003) Clinicopathologic evaluation after resection for ductal adenocarcinoma of the pancreas: a retrospective, single-institution experience. Pancreas 26(3):243–249

    Article  CAS  PubMed  Google Scholar 

  8. Katz MH, Pisters PWT, Evans DB, et al. (2008) Borderline resectable pancreatic cancer: the importance of this emerging stage of disease. J Am Coll Surg. 206(5): 833–846; discussion 846–848.

  9. guidelines N (2017) NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)-Pancreatic Cancer. www.nccn.org. April 27 2017.

  10. Callery MP, Chang KJ, Fishman EK, et al. (2009) Pretreatment assessment of resectable and borderline resectable pancreatic cancer: expert consensus statement. Ann Surg Oncol 16(7):1727–1733

    Article  PubMed  Google Scholar 

  11. Varadhachary GR, Tamm EP, Abbruzzese JL, et al. (2006) Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy. Ann Surg Oncol 13(8):1035–1046

    Article  PubMed  Google Scholar 

  12. Al-Hawary MM, Francis IR, Chari ST, et al. (2014) Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the society of abdominal radiology and the american pancreatic association. Gastroenterology 146(1):291 e1–304 e1

    Article  Google Scholar 

  13. Wang Z, Chen JQ, Liu JL, et al. (2013) FDG-PET in diagnosis, staging and prognosis of pancreatic carcinoma: a meta-analysis. World J Gastroenterol 19(29):4808–4817

    Article  PubMed  PubMed Central  Google Scholar 

  14. Rijkers AP, Valkema R, Duivenvoorden HJ, et al. (2014) Usefulness of F-18-fluorodeoxyglucose positron emission tomography to confirm suspected pancreatic cancer: a meta-analysis. Eur J Surg Oncol 40(7):794–804

    Article  CAS  PubMed  Google Scholar 

  15. Neoptolemos JP, Stocken DD, Friess H, et al. (2004) A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med 350(12):1200–1210

    Article  CAS  PubMed  Google Scholar 

  16. Oettle H, Post S, Neuhaus P, et al. (2007) Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA 297(3):267–277

    Article  CAS  PubMed  Google Scholar 

  17. Neoptolemos JP, Moore MJ, Cox TF, et al. (2012) Effect of adjuvant chemotherapy with fluorouracil plus folinic acid or gemcitabine vs observation on survival in patients with resected periampullary adenocarcinoma: the ESPAC-3 periampullary cancer randomized trial. JAMA 308(2):147–156

    Article  CAS  PubMed  Google Scholar 

  18. Neoptolemos JP, Palmer DH, Ghaneh P, et al. (2017) Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial. Lancet 389(10073):1011–1024

    Article  CAS  PubMed  Google Scholar 

  19. Katz MH, Crane CH, Varadhachary G (2014) Management of borderline resectable pancreatic cancer. Semin Radiat Oncol 24(2):105–112

    Article  PubMed  Google Scholar 

  20. Cheng TY, Sheth K, White RR, et al. (2006) Effect of neoadjuvant chemoradiation on operative mortality and morbidity for pancreaticoduodenectomy. Ann Surg Oncol 13(1):66–74

    Article  PubMed  Google Scholar 

  21. Evans DB, Varadhachary GR, Crane CH, et al. (2008) Preoperative gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head. J Clin Oncol 26(21):3496–3502

    Article  CAS  PubMed  Google Scholar 

  22. Varadhachary GR, Wolff RA, Crane CH, et al. (2008) Preoperative gemcitabine and cisplatin followed by gemcitabine-based chemoradiation for resectable adenocarcinoma of the pancreatic head. J Clin Oncol 26(21):3487–3495

    Article  CAS  PubMed  Google Scholar 

  23. Mehta VK, Fisher G, Ford JA, et al. (2001) Preoperative chemoradiation for marginally resectable adenocarcinoma of the pancreas. J Gastrointest Surg 5(1):27–35

    Article  CAS  PubMed  Google Scholar 

  24. Chuong MD, Springett GM, Freilich JM, et al. (2013) Stereotactic body radiation therapy for locally advanced and borderline resectable pancreatic cancer is effective and well tolerated. Int J Radiat Oncol Biol Phys 86(3):516–522

    Article  PubMed  Google Scholar 

  25. Takahashi H, Ohigashi H, Gotoh K, et al. (2013) Preoperative gemcitabine-based chemoradiation therapy for resectable and borderline resectable pancreatic cancer. Ann Surg 258(6):1040–1050

    Article  PubMed  Google Scholar 

  26. Paniccia A, Edil BH, Schulick RD, et al. (2014) Neoadjuvant FOLFIRINOX application in borderline resectable pancreatic adenocarcinoma: a retrospective cohort study. Medicine (Baltimore) 93(27):e198

    Article  CAS  Google Scholar 

  27. Sahora K, Kuehrer I, Eisenhut A, et al. (2011) NeoGemOx: gemcitabine and oxaliplatin as neoadjuvant treatment for locally advanced, nonmetastasized pancreatic cancer. Surgery 149(3):311–320

    Article  PubMed  Google Scholar 

  28. Sahora K, Kuehrer I, Schindl M, et al. (2011) NeoGemTax: gemcitabine and docetaxel as neoadjuvant treatment for locally advanced nonmetastasized pancreatic cancer. World J Surg 35(7):1580–1589

    Article  PubMed  Google Scholar 

  29. Lee JL, Kim SC, Kim JH, et al. (2012) Prospective efficacy and safety study of neoadjuvant gemcitabine with capecitabine combination chemotherapy for borderline-resectable or unresectable locally advanced pancreatic adenocarcinoma. Surgery 152(5):851–862

    Article  PubMed  Google Scholar 

  30. Katz MHG, Ou FS, Herman J, et al. (2017) Alliance for clinical trials in oncology (ALLIANCE) trial A021501: preoperative extended chemotherapy vs. chemotherapy plus hypofractionated radiation therapy for borderline resectable adenocarcinoma of the head of the pancreas. BMC Cancer 17(1):505

    Article  PubMed  PubMed Central  Google Scholar 

  31. Suker M, Beumer BR, Sadot E, et al. (2016) FOLFIRINOX for locally advanced pancreatic cancer: a systematic review and patient-level meta-analysis. Lancet Oncol 17(6):801–810

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Burris HA 3rd, Moore MJ, Andersen J, et al. (1997) Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial. J Clin Oncol 15(6):2403–2413

    Article  CAS  PubMed  Google Scholar 

  33. Conroy T, Desseigne F, Ychou M, et al. (2011) FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med 364(19):1817–1825

    Article  CAS  PubMed  Google Scholar 

  34. Gourgou-Bourgade S, Bascoul-Mollev C, Desseigne F, et al. (2013) Impact of FOLFIRINOX compared with gemcitabine on quality of life in patients with metastatic pancreatic cancer: results from the PRODIGE 4/ACCORD 11 randomized trial. J Clin Oncol 31(1):23–29

    Article  CAS  PubMed  Google Scholar 

  35. Von Hoff DD, Ervin T, Arena FP, et al. (2013) Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med 369(18):1691–1703

    Article  Google Scholar 

  36. Wang-Gillam A, Li CP, Bodoky G, et al. (2016) Nanoliposomal irinotecan with fluorouracil and folinic acid in metastatic pancreatic cancer after previous gemcitabine-based therapy (NAPOLI-1): a global, randomised, open-label, phase 3 trial. Lancet 387(10018):545–557

    Article  CAS  PubMed  Google Scholar 

  37. Le DT, Uram JN, Wang H, et al. (2015) PD-1 blockade in tumors with mismatch-repair deficiency. N Engl J Med 372(26):2509–2520

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Andre T, Lonardi S, Wong KYM et al. (2017) Combination of nivolumab (nivo) + ipilimumab (ipi) in the treatment of patients (pts) with deficient DNA mismatch repair (dMMR)/high microsatellite instability (MSI-H) metastatic colorectal cancer (mCRC): CheckMate 142 study. J Clin Oncol. 35: Abstr 3531.

  39. Nakata B, Wang YQ, Yashiro M, et al. (2002) Prognostic value of microsatellite instability in resectable pancreatic cancer. Clin Cancer Res 8(8):2536–2540

    CAS  PubMed  Google Scholar 

  40. Caligo MA, Ghimenti C, Sensi E, et al. (2000) Microsatellite alterations and K-ras, TGFbetaRII, IGFRII and bax mutations in sporadic cancers of the gastrointestinal tract. Oncol Rep 7(6):1371–1375

    CAS  PubMed  Google Scholar 

  41. Le DT, Durham JN, Smith KN, et al. (2017) Mismatch-repair deficiency predicts response of solid tumors to PD-1 blockade. Science. https://doi.org/10.1126/science.aan6733

    Google Scholar 

  42. Nishino M, Giobbie-Hurder A, Gargano M, et al. (2013) Developing a common language for tumor response to immunotherapy: immune-related response criteria using unidimensional measurements. Clin Cancer Res 19(14):3936–3943

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Goggins M, Schutte M, Lu J, et al. (1996) Germline BRCA2 gene mutations in patients with apparently sporadic pancreatic carcinomas. Cancer Res 56(23):5360–5364

    CAS  PubMed  Google Scholar 

  44. Jones S, Hruban RH, Kamiyama M, et al. (2009) Exomic sequencing identifies PALB2 as a pancreatic cancer susceptibility gene. Science 324(5924):217

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Ferrone CR, Levine DA, Tang LH, et al. (2009) BRCA germline mutations in Jewish patients with pancreatic adenocarcinoma. J Clin Oncol 27(3):433–438

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Chirnomas D, Taniguchi T, de la Vega M, et al. (2006) Chemosensitization to cisplatin by inhibitors of the Fanconi anemia/BRCA pathway. Mol Cancer Ther 5(4):952–961

    Article  CAS  PubMed  Google Scholar 

  47. Lowery MA, Kelsen DP, Stadler ZK, et al. (2011) An emerging entity: pancreatic adenocarcinoma associated with a known BRCA mutation: clinical descriptors, treatment implications, and future directions. Oncologist 16(10):1397–1402

    Article  PubMed  PubMed Central  Google Scholar 

  48. Fong PC, Kelsen DP, Stadler ZK, et al. (2009) Inhibition of poly(ADP-ribose) polymerase in tumors from BRCA mutation carriers. N Engl J Med 361(2):123–134

    Article  CAS  PubMed  Google Scholar 

  49. Hingorani SR, Harris WP, Beck JT, et al. (2016) Phase Ib study of PEGylated recombinant human hyaluronidase and gemcitabine in patients with advanced pancreatic cancer. Clin Cancer Res 22(12):2848–2854

    Article  CAS  PubMed  Google Scholar 

  50. Hingorani SR, Harris WP, Seery TE et al. (2016) Interim results of a randomized phase II study of PEGPH20 added to nab-paclitaxel/gemcitabine in patients with stage IV previously untreated pancreatic cancer. J Clin Oncol 34(suppl 4S)

  51. Bullock AJ, Hingorani SR, Wu XW, et al. (2016) Final analysis of stage 1 data from a randomized phase II study of PEGPH20 plus nab-Paclitaxel/gemcitabine in stage IV previously untreated pancreatic cancer patients (pts), utilizing Ventana companion diagnostic assay. J Clin Oncol 34(15):4104

    Google Scholar 

  52. Ozola Zalite I, Zykus R, Gonzalez MF, et al. (2014) Influence of cachexia and sarcopenia on survival in pancreatic ductal adenocarcinoma: a systematic review. Pancreatology 15(1):19–24

    Article  PubMed  Google Scholar 

  53. Antoun S, Borget I, Lanoy E (2013) Impact of sarcopenia on the prognosis and treatment toxicities in patients diagnosed with cancer. Curr Opin Support Palliat Care 7(4):383–389

    Article  PubMed  Google Scholar 

  54. Dalal S, Hui D, Bidaut L, et al. (2012) Relationships among body mass index, longitudinal body composition alterations, and survival in patients with locally advanced pancreatic cancer receiving chemoradiation: a pilot study. J Pain Symptom Manage 44(2):181–191

    Article  PubMed  PubMed Central  Google Scholar 

  55. Yamakado K, Nakatsuka A, Tanaka N, et al. (2001) Portal venous stent placement in patients with pancreatic and biliary neoplasms invading portal veins and causing portal hypertension: initial experience. Radiology 220(1):150–156

    Article  CAS  PubMed  Google Scholar 

  56. Novellas S, Denys A, Bize P, et al. (2009) Palliative portal vein stent placement in malignant and symptomatic extrinsic portal vein stenosis or occlusion. Cardiovasc Interv Radiol 32(3):462–470

    Article  Google Scholar 

  57. Iacobuzio-Donahue CA, Fu B, Yachida S, et al. (2009) DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 27(11):1806–1813

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Koay EJ, Baio FE, Ondari A, et al. (2014) Intra-tumoral heterogeneity of gemcitabine delivery and mass transport in human pancreatic cancer. Phys Biol 11(6):065002

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. University of Texas/MD Anderson Cancer Center, 1515 Holcombe Blvd Unit #426, Houston, TX, 77030, USA

    David R. Fogelman & Gauri Varadhachary

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  1. David R. Fogelman
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  2. Gauri Varadhachary
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Correspondence to David R. Fogelman.

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Dr. Fogelman has no conflicts of interest to report. Dr. Varadhachary has no conflicts of interest to report.

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Fogelman, D.R., Varadhachary, G. Medical oncology and pancreatic cancer: what the radiologist needs to know. Abdom Radiol 43, 383–392 (2018). https://doi.org/10.1007/s00261-017-1432-9

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