Preoperative FOLFIRINOX for borderline resectable pancreatic cancer: Is radiation necessary in the modern era of chemotherapy?

BACKGROUND: No consensus exists regarding the optimal neoadjuvant treatment paradigm for patients with borderline resectable pancreatic cancer (BRPC), including the respective roles of chemotherapy and radiation. METHODS: We performed a retrospective analysis, including detailed pathologic and radiologic review, of pancreatic cancer patients undergoing FOLFIRINOX, with or without radiation therapy (RT), prior to surgical resection at a high-volume academic center over a 4-year period. RESULTS: Of 26 patients meeting inclusion criteria, 22 (84.6%) received FOLFIRINOX alone without RT (median number of treatment cycles = 9). The majority of patients met formal radiographic criteria for BRPC, with the superior mesenteric vein representing the most common vessel involved. R0 resection rate was 90.9%, with 12 patients (54.5%) requiring vascular reconstruction. Treatment response was classified as moderate or marked in 16 patients (72.7%) according to the College of American Pathologists grading system. Estimated median disease-free and overall survival rates are 22.6 months and not reached (NR), respectively. CONCLUSIONS: This is one of the largest series to describe the use of neoadjuvant FOLFIRINOX, without radiation therapy, in patients with BRPC undergoing surgical resection. Given the high R0 resection rates and favorable clinical outcomes with chemotherapy alone, this strategy should be further assessed in prospective study design. J. Surg. Oncol. 2016;114:587-596. © 2016 Wiley Periodicals, Inc.

Downstaging of hepatocellular carcinoma prior to liver transplant: is there a role for adjuvant sorafenib in locoregional therapy?

Hepatocellular carcinoma (HCC) remains a common cause of mortality worldwide. Liver transplantation has emerged as the optimal treatment for cirrhotic patients with HCC; however, the shortage of donor organs leaves waitlisted patients at risk for disease progression beyond transplant criteria. Prevention of waitlist dropout has fueled investigation into a wide array of locoregional therapies for the management of HCC in candidates awaiting liver transplantation. We present a patient with HCC who underwent treatment with sorafenib, which resulted in a remarkable reduction in tumor burden to allow for liver transplant listing.

Immunosuppression: today, tomorrow, and withdrawal.

The advent of modern immunosuppressive agents is arguably the single most important factor that has allowed liver transplantation to advance in the past several decades from a dubious and dangerous venture to the treatment of choice for end-stage liver disease. During the past two decades, a large array of immunosuppressants have greatly expanded the armamentarium used by transplant physicians and surgeons to prevent and treat liver allograft rejection. The availability of these drugs has resulted in the excellent short-term and long-term outcomes achieved in liver transplantation. However, these drugs continue to lack specificity and are associated with acute and chronic toxicities. Although the liver is considered a relatively tolerogenic organ, we have yet to attain the "Holy Grail" of transplantation, that is, transplantation tolerance, in a consistent manner. Thus, the liver transplant recipient is still being sentenced to a lifelong course of chronic immunosuppression. Small molecules, biologic agents such as antibodies and fusion proteins, and corticosteroids continue to play a central role in immunosuppressive regimens used in liver transplantation. In addition several novel immunosuppressive agents have been used in preclinical and clinical trials that show promise for use in the near future. We review current immunosuppressive medications and describe the new developments that are on the horizon.