Guidelines Insights: Pancreatic Adenocarcinoma, Version 1.2019

Tempero, Margaret A.; Malafa, Mokenge P.; Chiorean, E. Gabriela; Czito, Brian G.; Scaife, Courtney L.; Narang, Amol; Fountzilas, Christos; Wolpin, Brian M.; Al-Hawary, Mahmoud M.; Asbun, Horacio J.; Behrman, Stephen W.; Benson, Al B.; Binder, Ellen F.; Cardin, Dana Backlund; Cha, Charles; Chung, Vincent; Dillhoff, Mary; Dotan, Efrat; Ferrone, Cristina R.; Fisher, George A.; Hardacre, Jeffrey M.; Hawkins, William G.; Ko, Andrew H.; LoConte, Noelle K.; Lowy, Andrew M.; Moravek, Cassadie; Nakakura, Eric K.; O'Reilly, Eileen Mary; Obando, Jorge; Reddy, Sushanth; Thayer, Sarah P.; Wolff, Robert A.; Burns, Jennifer L.; Zuccarino-Catania, Griselda

doi:10.6004/jnccn.2019.0014

Cited by 293 publications

(220 citation statements)

References 46 publications

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“…The recommendation for perioperative systemic treatment for patients with pancreatic ductal adenocarcinoma has prolonged survival rates . A Dutch study instituted neoadjuvant chemoradiotherapy for anatomic borderline tumors, with primary outcome to assess overall intention‐to‐treat survival.…”

Section: Discussionmentioning

confidence: 99%

Short‐term outcomes after vascular resection for pancreatic tumors: Lessons learned from 72 cases from a single Brazilian Cancer Center

Torres

Silva

Ribeiro

et al. 2019

Journal of Surgical Oncology

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Introduction Pancreatic malignant tumors are resectable at diagnosis in only 15% to 20% of cases and invasion of vascular structures is commonly present. Therefore, extended resections are needed for adequate local control and negative margins. However, morbidity and mortality associated with these enlarged resections are limiting factors. The aim of this study was to correlate demographic and technical aspects that influenced early and late outcomes. Materials and Methods Between October 2007 and May 2019, 523 pancreatic surgeries were performed, of which 72 required vascular resections. Clinical and histopathological data, surgical techniques, and perioperative parameters were analyzed in a prospectively collected database. Results Of the 72 cases of vascular resection, 31 were male and 41 females with a mean age of 60.9 years (34‐81). The most commonly affected vascular structure was the portal vein (in 40.3%). Free margins were obtained in 77.8% of cases. Postoperative mortality rate at 60 days was 13.9%. American Society of Anesthesiologists (ASA) and age were the most important predictors of major complications. Conclusion Extended resections with vascular involvement in pancreatic surgeries are feasible and safe; furthermore, patient selection plays are key. ASA and age were the most important factors in the decision‐making process for extended resections.

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Section: Discussionmentioning

confidence: 99%

Short‐term outcomes after vascular resection for pancreatic tumors: Lessons learned from 72 cases from a single Brazilian Cancer Center

Torres

Silva

Ribeiro

et al. 2019

Journal of Surgical Oncology

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“…The notion reflected in the NCCN (USA) guidelines stating that survival benefits from R1 resections may be comparable to definitive chemoradiation without surgery is based on outdated studies that report median overall survival times of only 12.3 months for R1 resections and are clearly inconsistent with recent data obtained in the context of the current state of the art of surgery and adjuvant chemotherapy (Table ) . Of note, the 5‐year overall survival rate after R1 resection with direct margin involvement can still be as high as 20%‐25% and is, therefore, much better than frequently discussed.…”

Section: Resection Margin Status and Survival In Pancreatic Cancermentioning

confidence: 95%

Local radicality and survival outcome of pancreatic cancer surgery

Niesen

Hank

Büchler

et al. 2019

Annals of Gastroent Surgery

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Pancreatic cancer remains a therapeutic challenge. Surgical resection in combination with systemic chemotherapy is the only option promising long‐term survival and potential cure. However, only about 20% of patients are diagnosed with tumors that are still in a resectable stage. Even after potentially curative resection and modern regimens for adjuvant chemotherapy, the majority of patients develop local and systemic recurrence resulting in median overall survival times of 28‐54 months. The predominance of systemic recurrence and its impact on survival may lead to the assumption that surgical radicality and local control play only minor roles in the treatment of pancreatic cancer. This review provides an overview of the recent literature on surgical radicality and survival outcome in pancreatic cancer. The current evidence on the extent of lymphadenectomy, the prognostic impact of the extent of lymph node involvement, and the impact of the resection margin status on postresection survival are reviewed. Data from recent studies performed in the context of modern surgery and adjuvant therapy provide good evidence of a considerable impact of local radicality on survival after pancreatic cancer surgery. Surgical techniques that have been developed to refine oncological resections and to increase local control as well as resectability are highlighted. These techniques include artery‐first approaches, level‐3 dissection with removal of the periarterial nerve plexus, the triangle operation, and extended resections. Local radicality and quality of surgical resection remain among the most important parameters that determine the chances for survival in patients with non‐metastatic pancreatic cancer.

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“…Evidence of improved survival has also been suggested based on data from cancer databases [10], meta-analyses of retrospective studies [14], and Markov decision models [15]. In turn, NT has become the preferred approach for borderline resectable (BR) PDAC, while guidelines support the use of either SF or NT for potentially resectable (PR) PDAC [16][17][18].Despite the theoretical and empirical advantages of NT, its use in the United States has remained relatively low [19,20], potentially driven by the lack of level I evidence for its efficacy. Until recently, only two small randomized controlled trials (RCTs) had been performed comparing SF to NT, and both were terminated early due to poor accrual [21,22].…”

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confidence: 99%

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confidence: 99%

Neoadjuvant Therapy for Resectable and Borderline Resectable Pancreatic Cancer: A Meta-Analysis of Randomized Controlled Trials

Cloyd

Heh

Pawlik

et al. 2020

JCM

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The efficacy of neoadjuvant therapy (NT) versus surgery first (SF) for pancreatic ductal adenocarcinoma (PDAC) remains controversial. A random-effects meta-analysis of only prospective randomized controlled trials (RCTs) comparing NT versus SF for potentially resectable (PR) or borderline resectable (BR) PDAC was performed. Among six RCTs including 850 patients, 411 (48.3%) received NT and 439 (51.6%) SF. In all included trials, NT was gemcitabine-based: four using chemoradiation and two chemotherapy alone. Based on an intention-to-treat analysis, NT resulted in improved overall survival (OS) compared to SF (HR 0.73, 95% CI 0.61-0.86). This effect was independent of anatomic classification (PR: hazard ratio (HR) 0.73, 95% CI 0.59-0.91; BR: HR 0.51 95% CI 0.28-0.93) or NT type (chemoradiation: HR 0.77, 95% CI 0.61-0.98; chemotherapy alone: HR 0.68, 95% CI 0.54-0.87). Overall resection rate was similar (risk ratio (RR) 0.93, 95% CI 0.82-1.04, I 2 = 39.0%) but NT increased the likelihood of a margin-negative (R0) resection (RR 1.51, 95% CI 1.18-1.93, I 2 = 0%) and having negative lymph nodes (RR 2.07, 95% CI 1.47-2.91, I 2 = 12.3%). In this meta-analysis of prospective RCTs, NT significantly improved OS in an intention-to-treat fashion, compared with SF for localized PDAC. Randomized controlled trials using contemporary multi-agent chemotherapy will be needed to confirm these findings and to define the optimal NT regimen.been associated with improved rates of margin-negative resection and a decreased incidence of lymph node metastases [10,11]. NT also offers several other theoretical benefits, including early treatment of presumed micro-metastatic disease, enhanced selection of patients with appropriate tumor biology for surgery, and the ability to histologically measure the response to therapy [12,13]. Evidence of improved survival has also been suggested based on data from cancer databases [10], meta-analyses of retrospective studies [14], and Markov decision models [15]. In turn, NT has become the preferred approach for borderline resectable (BR) PDAC, while guidelines support the use of either SF or NT for potentially resectable (PR) PDAC [16][17][18].Despite the theoretical and empirical advantages of NT, its use in the United States has remained relatively low [19,20], potentially driven by the lack of level I evidence for its efficacy. Until recently, only two small randomized controlled trials (RCTs) had been performed comparing SF to NT, and both were terminated early due to poor accrual [21,22]. Previous systematic reviews and meta-analyses that have purported a survival benefit with NT included non-randomized prospective and retrospective studies, which are limited due to their inherent selection biases [14,[23][24][25][26]. As several larger RCTs have recently been completed, albeit with older neoadjuvant regimens, the purpose of the current study was to perform a meta-analysis limited to only RCTs evaluating SF vs. NT for PDAC.

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Guidelines Insights: Pancreatic Adenocarcinoma, Version 1.2019

Cited by 293 publications

References 46 publications

Short‐term outcomes after vascular resection for pancreatic tumors: Lessons learned from 72 cases from a single Brazilian Cancer Center

Short‐term outcomes after vascular resection for pancreatic tumors: Lessons learned from 72 cases from a single Brazilian Cancer Center

Local radicality and survival outcome of pancreatic cancer surgery

Neoadjuvant Therapy for Resectable and Borderline Resectable Pancreatic Cancer: A Meta-Analysis of Randomized Controlled Trials

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