Development of chemotherapy and significance of conversion surgery after chemotherapy in unresectable pancreatic cancer

Abstract

While surgery currently remains the only potentially curative treatment available for pancreatic cancer, only 20% to 30% of patients have resectable disease at diagnosis. Recently, with the introduction of intensive chemotherapy regimens such as oxaliplatin, irinotecan, fluorouracil plus leucovorin (FOLFIRINOX) and gemcitabine plus nab-paclitaxel, for the treatment of unresectable pancreatic cancer, the antitumor activity and overall survival in patients with pancreatic cancer have dramatically improved. These advances in intensive chemotherapy have led to the possibility of conversion of unresectable disease to resectable disease, and it has been reported that more than 20% of pancreatic cancer patients with unresectable locally advanced disease at diagnosis undergo successful conversion surgery after FOLFIRINOX therapy. In metastatic pancreatic cancer, resection for the primary lesion of pancreatic cancer may show some benefits for some patients with complete resolution of metastases by chemotherapy. Furthermore, surgical resection in some patients with only a few metastases, so-called oligometastases, have also been reported. Conversion surgery is becoming increasingly possible with the introduction of intensive chemotherapies, however, the actual clinical benefits of resection in such cases has not yet been sufficiently investigated. The long-term safety, feasibility and outcomes still need to be investigated in well-designed, multi-institutional studies on a large number of patients.

Neutrophil to lymphocyte ratio predicts prognosis in unresectable pancreatic cancer

“…Pancreatic cancer is one of the most aggressive types, with 5-year overall survival (OS) rate < 10% 1 , 2 . Due to the difficulty in early detection, most patients present with unresectable disease, and less than 30% of patients have resectable tumors when diagnosed 3 . Intensive chemotherapy regimens such as FOLFIRINOX and Gem plus nab-paclitaxel has been developed 4 , 5 , however, the median OS was 8.5–11.1 months in these clinical trials.…”

Conversion Therapy for Advanced Pancreatic Cancer: The Case Series and Literature Review

“…Does it mean a total loss of surgery for unresectable pancreatic cancer? Providing these patients with surgical opportunities through comprehensive treatment plays an increasingly important role in the recent clinical practice (Furuse et al, 2018). After a period of conversion therapy, the primary and metastatic lesions in patients with metastatic pancreatic cancer who are sensitive to chemotherapy will gradually shrink or even reach R0 resection (Sakuraba et al, 2013;Maeda et al, 2014;Koga et al, 2014;Makino et al, 2015).…”

“…For advanced pancreatic cancer, there is no chance of surgery at the time of initial diagnosis. However, conversion therapy can turn this impossible situation into a possible (Frigerio et al, 2017;Furuse et al, 2018). The purpose of conversion therapy is to reduce the size of the tumor using radiotherapy, chemotherapy, or targeted therapy.…”

Conversion surgery for initially unresectable carcinoma of the ampulla of Vater following pathological complete response to chemotherapy: a case report

“…Recent advances in chemotherapy have led to several cases of successful conversion surgery in patients with advanced biliary tract cancer or pancreatic cancer, as for patients with colorectal cancer [14–16]. However, because no comprehensive reports are available, no consensus has been reached regarding the timing of resection, its impact on the prognosis, or the need for postoperative adjuvant therapy.…”