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Heavy-duty Multimodal Therapy with RFA for Locally Advanced Pancreatic Cancer

In some ways, both early stage and late stage pancreatic cancer (under current thinking paradigms) may be easier stages in which to offer standard care: early receives surgery (without or without neoadjuvant or adjuvant augmentation), and late stage is typically chemotherapy in one combination or another – at least initially involving either gemcitabine or 5-FU.  These approaches are of course always changing as challenges move the cutting edge of science and medicine forward.  The recent modest breakthrough on nab-paclitaxel (Abraxane) plus gemcitabine presented by Von Hoff et al. in San Francisco in January is perhaps a case in point.

But at least for now, it is often the middle presenting disease stages – locally advanced pancreatic cancer – that do not present easier logical choices. So it is with some interest that we find in the August issue of HPB, the official journal of the International Hepato Pancreato Biliary Association, that Pederzoli and colleagues from Casa di Cura Pederzoli, Peschiera del Garda of Italy have published an intriguing study reflecting the results of an aggressive treatment protocol for locally advanced adenocarcinoma of the pancreas.

The researchers did a retrospective study of the outcomes of multimodal treatment (“Triple Treatment”) on locally advanced pancreatic cancer with radiofrequency ablation (“RFA”), radiochemotherapy, together with systemic as well as intra-arterial chemotherapy. They reviewed the results of 168 consecutive patients who had been treated with initial OR subsequent RFA (from 2007 until 2011), discovering that the median survival of these groups was roughly the same at about 25 months.  This was in comparison to the group which had received the more specific and aggressive Triple Treatment modality regimen which carried a subsequent overall median survival duration of 34 months.

This research carries the inherent limitations of what appears to be a nested retrospective study, but represents an interesting hypothesis – maybe especially in this time of more aggressive combinations (such as FOLFIRINOX)  – and as such is highly deserving of further study.

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Dale O’Brien, MD

Hepatitis as a Risk Factor for Cancer of the Pancreas

A number of “odd’ or non-intuitive relationships between “apparently” unrelated variables and pancreatic cancer are beginning to emerge – including ABO blood status and now some forms of hepatitis.

In the World Journal of Gastroenterology from July 14, 2013, Chen and colleagues from the Southern Medical University, in Guangzhou, China report a meta-analysis of a world review of the medical literature on the relationship between infection with the hepatitis B virus (HBV) and the hepatitis C virus (HCV) AND pancreatic cancer. Using their developed criteria, they found eight studies that were eligible for inclusion in their analysis pool.

The researchers found a small but statistically significant association between chronic HBV and HCV infections and the risk of developing adenocarcinoma of the pancreas. The odds ratio for a patient’s status of the presence of inactive hepatitis surface antigen (HBsAg) and for chronic hepatitis B exposure was 1.2 at a 95% confidence interval – with Chinese patients appearing even somewhat higher (1.3). And the odds ratio for past exposure to the hepatitis C virus was somewhat similar at 1.26. The authors indicate that there is no evidence of publication bias in these associations.

It is not entirely clear what these findings mean. But finding association between pancreatic cancer and possible acute (or chronic?) triggers moves the science further along the cutting edge of understanding.

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Dale O’Brien, MD

Cryotherapy plus Biologic Therapy for Advanced Cancer of the Pancreas

It is the impression of this author that in the past decade or so the quantity and quality of published medical research coming from China has increased rather remarkably. This has included challenges to “standard” established practice – with innovative ideas particularly on the treatment of pancreatic cancer. Now comes a study from China involving cryotherapy, a surgical “ablation” (or removal) procedure that attempts to use a freeze technique to destroy malignant tissue.

On July 30th, Vu and colleagues from Jinan University in Guangzhou, China published an article in the journal Pancreas that divided 106 patients with metastatic pancreatic cancer into four groups depending of treatment modality: cryotherapy in combination with immunotherapy, cryotherapy alone, immunotherapy alone, and chemotherapy. They reported out the median overall survival duration of the groups with some elaboration, finding that the median survival of the cryotherapy and immunotherapy in combination group was much longer than the others (13 months). Their work also found the median OS was increased if multiple cryoablations were used (rather than a single such treatment).

This is very interesting early work on this combination modality for metastatic pancreatic cancer. This approach appears worthy of further work to see if the results stand up to scrutiny.

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Dale O’Brien, MD

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