Neoadjuvant treatment strategies for intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma(ICC)is the second most common primary liver malignancy and is increasing in incidence.Long-term outcomes are optimized when patients undergo margin-negative resection followed by adjuvant chemotherapy.Unfortunately,a significant proportion of patients present with locally advanced,unresectable disease.Furthermore,recurrence rates are high even among patients who undergo surgical resection.The delivery of systemic and/or liver-directed therapies prior to surgery may increase the proportion of patients who are eligible for surgery and reduce recurrence rates by prioritizing early systemic therapy for this aggressive cancer.Nevertheless,the available evidence for neoadjuvant therapy in ICC is currently limited yet recent advances in liver directed therapies,chemotherapy regimens,and targeted therapies have generated increasing interest its role.In this article,we review the rationale for,current evidence for,and ongoing research efforts in the use of neoadjuvant therapy for ICC.

Contemporary indications for and outcomes of hepatic resection for neuroendocrine liver metastases

BACKGROUND Although surgical resection is associated with the best long-term outcomes for neuroendocrine liver metastases(NELM),the current indications for and outcomes of surgery for NELM from a population perspective are not well understood.AIM To determine the current indications for and outcomes of liver resection(LR)for NELM using a population-based cohort.METHODS A retrospective review of the 2014-2017 American College of Surgeons National Surgical Quality Improvement Program and targeted hepatectomy databases was performed to identify patients who underwent LR for NELM.Perioperative characteristics and 30-d morbidity and mortality were analyzed.RESULTS Among 669 patients who underwent LR for NELM,the median age was 60(interquartile range:51-67)and 51%were male.While the number of metastases resected ranged from 1 to 9,the most common(45%)number of tumors resected was one.The majority(68%)of patients had a largest tumor size of<5 cm.Most patients underwent partial hepatectomy(71%)while fewer underwent a right or left hepatectomy or trisectionectomy.The majority of operations were open(82%)versus laparoscopic(17%)or robotic(1%).In addition,30%of patients underwent intraoperative ablation while 45%had another concomitant operation including cholecystectomy(28.8%),bowel resection(20.2%),or partial pancreatectomy(3.4%).Overall 30-d morbidity and mortality was 29%and 1.3%,respectively.On multivariate analysis,American Society of Anesthesiologists class≥3[odds ratios(OR),OR=2.089,95%confidence intervals(CI):1.197-3.645],open approach(OR=1.867,95%CI:1.148-3.036),right hepatectomy(OR=1.618,95%CI:1.014-2.582),and prolonged operative time of>230 min(OR=1.731,95%CI:1.168-2.565)were associated with higher 30-d morbidity while intraoperative ablation and concomitant procedures were not.CONCLUSION LR for NELM was performed with relatively low postoperative morbidity and mortality.Concomitant procedures performed at the time of LR did not increase morbidity.

Neoadjuvant therapy for pancreatic ductal adenocarcinoma:Opportunities for personalized cancer care

Pancreatic ductal adenocarcinoma(PDAC)is an aggressive malignancy that is best treated in a multidisciplinary fashion using surgery,chemotherapy,and radiation.Adjuvant chemotherapy has shown to have a significant survival benefit in patients with resected PDAC.However,up to 50%of patients fail to receive adjuvant chemotherapy due to postoperative complications,poor patient performance status or early disease progression.In order to ensure the delivery of chemotherapy,an alternative strategy is to administer systemic treatment prior to surgery.Precision oncology refers to the application of diverse strategies to target therapies specific to characteristics of a patient’s cancer.While traditionally emphasized in selecting targeted therapies based on molecular,genetic,and radiographic biomarkers for patients with metastatic disease,the neoadjuvant setting is a prime opportunity to utilize personalized approaches.In this article,we describe the current evidence for the use of neoadjuvant therapy(NT)and highlight unique opportunities for personalized care in patients with PDAC undergoing NT.

Characterizing the patient experience during neoadjuvant therapy for pancreatic ductal adenocarcinoma:A qualitative study

BACKGROUND Neoadjuvant therapy(NT)has increasingly been utilized for patients with localized pancreatic ductal adenocarcinoma(PDAC).It is the recommended approach for borderline resectable(BR)and locally advanced(LA)cancers and an increasingly utilized option for potentially resectable(PR)disease.Despite its increased use,little research has focused on patient-centered metrics among patients undergoing NT,including patient experiences,preferences,and recommendations.A better understanding of all aspects of the patient experience during NT may identify opportunities to design interventions aimed at improving quality of life;it may also facilitate the completion of NT and receipt of surgery,ultimately optimizing long-term outcomes.AIM To understand the experience of patients initiating and receiving NT to identify opportunities to improve neoadjuvant cancer care delivery.METHODS Semi-structured interviews of patients with localized PDAC during NT were conducted to explore their experience initiating and receiving NT.Interviews took place between August 2020 and October 2021.Due to the descriptive nature of the research,questions were open ended.Interviews were conducted over the phone,audio recorded and then transcribed.All interviews were coded by two independent researchers using NVivo 12,iteratively identifying themes until thematic saturation was achieved.An integrative approach to qualitative analysis was used,utilizing both inductive and deductive methods.RESULTS A total of 12 patients with localized PDAC were interviewed.Patients with BR(n=7),PR(n=2),and LA(n=3)cancers participated in the study.All patients indicated that choosing NT was the doctor’s recommendation,while most reported not being familiar with the concept of NT(n=11)and that NT was presented as the only option(n=8).Five themes describing the patient experience emerged:physical symptoms,emotional symptoms,coping mechanisms,access to care,and life factors.The most commonly cited recommendation for improving the experience of NT was improved education before and during NT(n=7).Patients highlighted the need for more information on the rationale behind choosing NT prior to surgery,the anticipated surgery and its likelihood of surgery occurring after NT,as well as general information prior to starting NT treatment.The need for seeing different members of the healthcare team,including ancillary services was also frequently cited as a recommendation for improving the experience of NT(n=5).CONCLUSION This study provides a framework to allow for a better understanding of the PDAC patient experience during NT and highlights opportunities to improve quality and quantity of life outcomes.