Favorable perioperative outcomes after resection of borderline resectable pancreatic cancer treated with neoadjuvant stereotactic radiation and chemotherapy compared with upfront pancreatectomy for resectable cancer

Mellon, Eric A.; Ström, T.; Hoffe, Sarah E.; Frakes, Jessica M.; Springett, Gregory M.; Hodul, Pamela J.; Malafa, Mokenge P.; Chuong, Michael D.; Shridhar, Ravi

doi:10.21037/jgo.2016.03.15

Cited by 44 publications

(36 citation statements)

References 30 publications

(31 reference statements)

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“…In our results, having Stage III disease was the most significant predictor of overall survival. This also concurs with the current literature that even in patients with clinically evident cachexia, secondary sarcopenia, or decreased visceral fat adiposity, survival is contingent on whether they proceed to resection (21,(72)(73)(74)(75), which is uncertain in these BRPC and LAPC patient populations.…”

Section: Discussionsupporting

confidence: 90%

Impact of sarcopenia in borderline resectable and locally advanced pancreatic cancer patients receiving stereotactic body radiation therapy

Jin¹,

Mellon²,

Frakes³

et al. 2018

J. Gastrointest. Oncol.

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Background: Total psoas area (TPA), a marker of sarcopenia, has been used as an independent predictor of clinical outcomes in gastrointestinal (GI) cancers as a proxy for frailty and nutritional status. Our study aimed to evaluate whether TPA, in contrast to traditional measurements of nutrition like body mass index (BMI) and body surface area (BSA), was predictive of outcomes in borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC) patients receiving stereotactic body radiation therapy (SBRT). Methods: Retrospective analysis of an institutional review board approved database of 222 BRPC and LAPC treated with SBRT from 2009-2016 yielded 183 patients that met our selection criteria of pre-SBRT computed tomography (CT) imaging with an identifiable L4 vertebra. Once the L4 vertebral level was identified, the bilateral psoas muscles were manually contoured. This area was normalized by patient height, with units described in mm 2 /m 2 . Receiver operating characteristic (ROC) curves were generated for TPA, BMI, and BSA to elicit clinically relevant cutoffs. Regression and Kaplan-Meier analyses were used to correlate toxicity with survival functions.Results: Low TPA (OR =1.903, P=0.036) was predictive of acute toxicities, and only TPA was predictive of Grade 3 or higher acute toxicities (OR =10.24, P=0.007). Both findings were independent of tumor resectability. Pain (P=0.003), fatigue (P=0.040), and nausea (P=0.039) were significantly associated with low TPA. No association was identified between any measurement of nutritional status and the development of late toxicities, overall survival, local progression or local recurrence. However, BRPC patients survived longer (median =21.98 months) than their LAPC (median =16.2 months) counterparts (P=0.002), independent of nutritional status. Conclusions: TPA measurement is readily available and more specific than BMI or BSA as a predictor of acute radiotoxic complications following SBRT in BRPC/LAPC patients. A TPA of <500 mm 2 /m 2 is a clinically relevant cutoff that can direct physicians to address expected complications of pain, fatigue, and nausea. However, tumor resectability remains as the only predictor of overall survival in this cohort.

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Section: Discussionsupporting

confidence: 90%

Impact of sarcopenia in borderline resectable and locally advanced pancreatic cancer patients receiving stereotactic body radiation therapy

Jin¹,

Mellon²,

Frakes³

et al. 2018

J. Gastrointest. Oncol.

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“…26 A more recent, larger series of 61 patients with BRPC/LAPC treated with neoadju- vant and resected reported no significant difference in postopera- tive morbidity compared with those who underwent upfront resec- tion 27 , however, a comparison of postoperative mortality between modalities of radiation in a large population has not been per- formed. Our study presented a cohort of patients with BRPC/LAPC treated with neoadjuvant combination therapy and subsequent re- section.…”

Section: Discussionmentioning

confidence: 99%

Postoperative complications after resection of borderline resectable and locally advanced pancreatic cancer: The impact of neoadjuvant chemotherapy with conventional radiation or stereotactic body radiation therapy

Blair

Rosati

Rezaee

et al. 2018

Surgery

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Background: The impact of neoadjuvant stereotactic body radiation therapy on postoperative complications for patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma remains unclear. Limited studies have compared neoadjuvant stereotactic body radiation therapy versus conventional chemoradiation therapy. A retrospective study was performed to determine if perioperative complications were different among patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma receiving neoadjuvant stereotactic body radiation therapy or chemoradiation therapy. Methods: Patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma who underwent neoadjuvant chemotherapy with stereotactic body radiation therapy or chemoradiation therapy followed by pancreatectomy at the Johns Hopkins Hospital between 2008 and 2015 were included Predictive factors for severe complications (Clavien grade ≥ III) were assessed by univariate and multivariate analyses. Results: A total of 168 patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma underwent neoadjuvant chemotherapy and RT followed by pancreatectomy. Sixty-one (36%) patients underwent stereotactic body radiation therapy and 107 (64%) patients received chemoradiation therapy. Compared with the chemoradiation therapy cohort, the neoadjuvant stereotactic body radiation therapy cohort was more likely to have locally advanced pancreatic ductal adenocarcinoma (62% vs 43% P = .017) and a require vascular resection (54% vs 37%, P = .027). Multiagent chemotherapy was used more commonly in the stereotactic body radiation therapy cohort (97% vs 75%, P < .001). Postoperative complications (Clavien grade ≥ III 23% vs 28%, P = .471) were similar between stereotactic body radiation therapy and chemoradiation therapy cohort. No significant difference in postoperative bleeding or infection was noted in either group. Conclusion: Compared with chemoradiation therapy, neoadjuvant stereotactic body radiation therapy appears to offer equivalent rates of perioperative complications in patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma despite a greater percentage of locally advanced disease and more complex operative treatment.

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“…NT in resectable pancreatic cancer has also proven to have a higher R0 resection rate. A few prospective studies have demonstrated up to 100% R0 resection rates with the use of NT in resectable pancreatic cancer (6,20). These studies are limited by their small sample sizes.…”

Section: Discussionmentioning

confidence: 99%

“…Counter arguments that some patients will develop disease progression who would have been otherwise been potentially curable with an upfront surgery approach given the poor response rates to a neoadjuvant approach. It has been reported that neoadjuvant treatment improves median and overall survival in resectable and borderline resectable pancreatic cancer (17)(18)(19)(20). However, there has never been a study on the survival of patients receiving NT stratified by size of the tumor.…”

Section: Introductionmentioning

confidence: 99%

Correlation of tumor size and survival in pancreatic cancer

Takahashi¹,

Shridhar²,

Huston³

et al. 2018

J. Gastrointest. Oncol.

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Background: Neoadjuvant therapy (NT) for resectable pancreatic adenocarcinoma (PAC) continues to be debated. We sought to establish the relationship between pancreatic tumor size, neoadjuvant chemotherapy (NCT), neoadjuvant chemoradiation (NCRT), and definitive surgery (DS) on survival.Methods: Utilizing the National Cancer Database we identified patients with PAC who underwent NT and DS. Patient characteristics and survival were compared with Mann-Whitney U, Pearson's Chi-square, and the Kaplan-Meier method. Multivariable analysis (MVA) was developed to identify predictors of survival. All tests were two-sided and α <0.05 was significant. Results: We identified 11,707 patients: 9,722 patients with tumors >2 cm and 1,985 with tumors ≤2 cm.There were 523 patients treated with NCT, 559 treated with NCRT, and 10,625 DS. Patients with tumors >2 cm were more likely to have higher T-stage, P<0.001, positive lymph nodes, P<0.001, poor histologic grade, P<0.001, and R1 resections, P<0.001. The median survival for patients with tumors ≤2 cm was 30.6 months compared to 20.5 months for those whose tumors were >2 cm, P<0.001. In the >2 cm groups the median survival for NCT, NCRT, and DS was 22.9, 25.8 and 21.3 months, P=0.01. MVA revealed that age, Charlson/Deyo score, N-stage, grade, tumor size >2 cm, R0 resection, and NT were predictors of survival. Ninety-day mortality was worse in both the NCT and NCRT compared to DS, P<0.001. Conclusions: The size of pancreatic cancer correlates to pathologic stage and overall survival. Tumors >2 and <2 cm benefited from a NT. However, the 90-operative mortality was significantly worse in those patients receiving NT.

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Favorable perioperative outcomes after resection of borderline resectable pancreatic cancer treated with neoadjuvant stereotactic radiation and chemotherapy compared with upfront pancreatectomy for resectable cancer

Cited by 44 publications

References 30 publications

Impact of sarcopenia in borderline resectable and locally advanced pancreatic cancer patients receiving stereotactic body radiation therapy

Impact of sarcopenia in borderline resectable and locally advanced pancreatic cancer patients receiving stereotactic body radiation therapy

Postoperative complications after resection of borderline resectable and locally advanced pancreatic cancer: The impact of neoadjuvant chemotherapy with conventional radiation or stereotactic body radiation therapy

Correlation of tumor size and survival in pancreatic cancer

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