Preoperative Exercise during Neoadjuvant Therapy for Pancreatic Cancer: A Pilot Study

Exercise improves cancer treatment outcomes including health-related quality of life and physical functioning. Patients with pancreatic cancer are generally older adults, and frailty and cachexia are prevalent. Chemotherapy and chemoradiation are increasingly administered prior to pancreatic cancer surgery, and sarcopenia has been shown to accompany these therapies. Preoperative exercise may improve health, well-being, and perioperative outcomes among patients undergoing preoperative therapy for pancreatic cancer. The purpose of this pilot study was to determine the feasibility of exercise in this context. Feasibility was defined as patients completing, on average, 60% of recommended weekly exercise minutes. Twenty patients (M=64 years old, SD=9.9; 42% female) enrolled in a home-based exercise program during preoperative therapy (chemotherapy and/or chemoradiation and preoperative “rest”, M=21.2 weeks total, SD=16.4). Exercise recommendations included moderate-intensity walking for 20-30 minutes/day on ≥3 days/week and moderate-intensity resistance exercises for 30-45 minutes/day on ≥2 days/week. Exercise recommendations (120 minutes of moderate-intensity activity/week) were based on American College of Sports Medicine and American Cancer Society recommendations (150 minutes of moderate-intensity activity/week), but reduced due to patients’ older age and concurrent preoperative therapy. Resistance exercises targeted upper body, lower body, and abdominal muscles, and patients were instructed to perform 3 sets of 8-12 repetitions of multiple exercises for each region during each session. Patients received Yamax Digiwalker pedometers, graded resistance tube sets, and booklets and DVDs with instructions and safety tips. Research staff provided detailed instructions and resistance exercise demonstrations at enrollment and monitored and encouraged adherence with biweekly phone calls. Patients recorded minutes of walking and resistance exercise in daily logs. On average, patients reported 73.9 minutes of walking (\u3e100% of recommendation, SD=72.4) and 43.1 minutes of resistance exercise per week (71.8% of recommendation, SD=39.0). Patients reported the most walking during chemoradiation (M=94.7 minutes/week, SD=104.3), followed by preoperative “rest” (M=77.4 minutes/week, SD=80.4), and chemotherapy (M=70.8 minutes/week, SD=75.2). Patients reported the most resistance exercise during the preoperative “rest” period (M=51.6 minutes/week, SD=52.3), followed by chemoradiation (M=38.0 minutes/week, SD=36.8), and chemotherapy (M=31.1 minutes/week, SD=38.1). Walking and resistance exercise are feasible for patients undergoing preoperative therapy for pancreatic cancer. Varying levels of fatigue and treatment-related side effects may affect exercise during different treatment phases

Yield of clinical and radiographic surveillance in patients with resected pancreatic adenocarcinoma following multimodal therapy

AbstractBackgroundFollowing potentially curative resection at this centre, patients with pancreatic adenocarcinoma (PAC) are routinely enrolled in a programme of clinical and radiographic surveillance. This study sought to evaluate its diagnostic yield.MethodsAll patients who underwent pancreaticoduodenectomy for PAC at this institution during 1998–2008 were identified. Patients with asymptomatic recurrence were compared with those with symptomatic recurrence. Factors associated with survival following the detection of recurrence were compared.ResultsA total of 216 of 327 (66.1%) resected patients developed recurrence. Asymptomatic recurrence was detected in 118 (54.6%) patients. Symptomatic recurrence was associated with multifocal disease or carcinomatosis, poor performance status and less frequent subsequent therapy. Median time to recurrence did not differ between groups, but survival after detection was shorter in symptomatic patients (5.1months vs. 13.0months; P < 0.001). Treatment was administered more frequently to asymptomatic patients (91.2% vs. 61.4%; P < 0.001). At recurrence, a preserved performance status score of ≤1, further therapy, low CA 19-9, and an isolated site of recurrence were independently associated with longer post-recurrence survival (P < 0.001).ConclusionsOverall, 54.6% of cases of recurrent PAC were detected prior to the onset of symptoms using a standardized clinical and radiographic surveillance strategy. Although this retrospective analysis limits definitive conclusions associating this strategy with survival, these results suggest the need for further studies of postoperative surveillance

Impact of a non-therapeutic laparotomy in patients with locally advanced pancreatic cancer treated with induction (m)FOLFIRINOX:Trans-Atlantic Pancreatic Surgery (TAPS) Consortium study

Background: Surgery in selected patients with locally advanced pancreatic cancer after induction chemotherapy may have drawbacks related to surgical risks and breaks or delays in oncological treatment, in particular when curative intent resection is not possible (that is non-therapeutic laparotomy). The aim of this study was to assess the incidence and oncological impact of a non-therapeutic laparotomy in patients with locally advanced pancreatic cancer treated with induction (m)FOLFIRINOX chemotherapy. Methods : This was a retrospective international multicentre study including patients diagnosed with pathology-proven locally advanced pancreatic cancer treated with at least one cycle of (m)FOLFIRINOX (2012–2019). Patients undergoing a non-therapeutic laparotomy (group A) were compared with those not undergoing surgery (group B) and those undergoing resection (group C). Results : Overall, 663 patients with locally advanced pancreatic cancer were included (67 patients (10.1%) in group A, 425 patients (64.1%) in group B, and 171 patients (25.8%) in group C). A non-therapeutic laparotomy occurred in 28.2% of all explorations (67 of 238), with occult metastases in 30 patients (30 of 67, 44.8%) and a 90-day mortality rate of 3.0% (2 of 67). Administration of palliative therapy (65.9% versus 73.1%; P = 0.307) and median overall survival (20.4 [95% c.i. 15.9 to 27.3] versus 20.2 [95% c.i. 19.1 to 22.7] months; P = 0.752) did not differ between group A and group B respectively. The median overall survival in group C was 36.1 (95% c.i. 30.5 to 41.2) months. The 5-year overall survival rates were 11.4%, 8.7%, and 24.7% in group A, group B, and group C, respectively. Compared with group B, non-therapeutic laparotomy (group A) was not associated with reduced overall survival (HR = 0.88 [95% c.i. 0.61 to 1.27]). Conclusion: More than a quarter of surgically explored patients with locally advanced pancreatic cancer after induction (m) FOLFIRINOX did not undergo a resection. Such non-therapeutic laparotomy does not appear to substantially impact oncological outcomes.</p

Impact of a non-therapeutic laparotomy in patients with locally advanced pancreatic cancer treated with induction (m)FOLFIRINOX:Trans-Atlantic Pancreatic Surgery (TAPS) Consortium study

Background: Surgery in selected patients with locally advanced pancreatic cancer after induction chemotherapy may have drawbacks related to surgical risks and breaks or delays in oncological treatment, in particular when curative intent resection is not possible (that is non-therapeutic laparotomy). The aim of this study was to assess the incidence and oncological impact of a non-therapeutic laparotomy in patients with locally advanced pancreatic cancer treated with induction (m)FOLFIRINOX chemotherapy. Methods : This was a retrospective international multicentre study including patients diagnosed with pathology-proven locally advanced pancreatic cancer treated with at least one cycle of (m)FOLFIRINOX (2012–2019). Patients undergoing a non-therapeutic laparotomy (group A) were compared with those not undergoing surgery (group B) and those undergoing resection (group C). Results : Overall, 663 patients with locally advanced pancreatic cancer were included (67 patients (10.1%) in group A, 425 patients (64.1%) in group B, and 171 patients (25.8%) in group C). A non-therapeutic laparotomy occurred in 28.2% of all explorations (67 of 238), with occult metastases in 30 patients (30 of 67, 44.8%) and a 90-day mortality rate of 3.0% (2 of 67). Administration of palliative therapy (65.9% versus 73.1%; P = 0.307) and median overall survival (20.4 [95% c.i. 15.9 to 27.3] versus 20.2 [95% c.i. 19.1 to 22.7] months; P = 0.752) did not differ between group A and group B respectively. The median overall survival in group C was 36.1 (95% c.i. 30.5 to 41.2) months. The 5-year overall survival rates were 11.4%, 8.7%, and 24.7% in group A, group B, and group C, respectively. Compared with group B, non-therapeutic laparotomy (group A) was not associated with reduced overall survival (HR = 0.88 [95% c.i. 0.61 to 1.27]). Conclusion: More than a quarter of surgically explored patients with locally advanced pancreatic cancer after induction (m) FOLFIRINOX did not undergo a resection. Such non-therapeutic laparotomy does not appear to substantially impact oncological outcomes.</p

Transcriptomic Profile of Lymphovascular Invasion, a Known Risk Factor of Pancreatic Ductal Adenocarcinoma Metastasis

Lymphovascular invasion (LVI) is an aggressive pathologic feature and considered a risk factor for distant metastasis. We hypothesized that pancreatic ductal adenocarcinomas (PDACs) with LVI are associated with shorter survival, as well as aggressive cancer biology and lymphangiogenesis in transcriptomic analysis. Utilizing the cancer genome atlas (TCGA)-PDAC cohort, we found that positive LVI was significantly associated with positive perineural invasion (PNI) (p = 0.023), and higher American Joint Committee on Cancer (AJCC) T (p = 0.017) and N (p &lt; 0.001) categories. Furthermore, positive LVI was associated with shorter overall survival (OS) (p = 0.014) and was an independent risk factor of poor OS. Although there was no association between LVI status and lymphangiogenesis, epithelial-mesenchymal transition (EMT), or metastasis-related genes, Gene Set Enrichment Analysis revealed a strong association with cell-proliferation-related gene sets such as mitotic spindles (Normalized enrichment score (NES) = 1.76, p = 0.016) and G2/M checkpoints (NES = 1.75, p = 0.036), as well as with transforming growth factor beta (TGF-beta) signaling (NES = 1.61, p = 0.043), which is a known mechanism of metastasis in PDACs. In conclusion, positive LVI was an independent risk factor of poor OS in PDACs. We found that PDACs with LVI were possibly associated with accelerated cell proliferation and enhanced TGF-beta signaling independent of lymphangiogenesis. Transcriptomic profiling elucidates more precise tumor biology of LVI-positive PDACs

Novel recA-Independent Horizontal Gene Transfer in Escherichia coli K-12.

In bacteria, mechanisms that incorporate DNA into a genome without strand-transfer proteins such as RecA play a major role in generating novelty by horizontal gene transfer. We describe a new illegitimate recombination event in Escherichia coli K-12: RecA-independent homologous replacements, with very large (megabase-length) donor patches replacing recipient DNA. A previously uncharacterized gene (yjiP) increases the frequency of RecA-independent replacement recombination. To show this, we used conjugal DNA transfer, combining a classical conjugation donor, HfrH, with modern genome engineering methods and whole genome sequencing analysis to enable interrogation of genetic dependence of integration mechanisms and characterization of recombination products. As in classical experiments, genomic DNA transfer begins at a unique position in the donor, entering the recipient via conjugation; antibiotic resistance markers are then used to select recombinant progeny. Different configurations of this system were used to compare known mechanisms for stable DNA incorporation, including homologous recombination, F'-plasmid formation, and genome duplication. A genome island of interest known as the immigration control region was specifically replaced in a minority of recombinants, at a frequency of 3 X 10(-12) CFU/recipient per hour