Neoadjuvant therapy prior to surgical resection for previously explored pancreatic cancer patients is associated with improved survival

Abstract

Background: Patients with pancreatic ductal adenocarcinoma (PDAC) are frequently referred to tertiary centers after unsuccessful attempted resections at other institutions. The outcome of these patients who are ultimately resected is not well understood. Methods:We performed a retrospective review of patients with PDAC who underwent re-exploration between 1995 and 2013 at a single high volume tertiary care institution. We aimed to evaluate the association of neoadjuvant therapy prior to re-exploration on pathologic findings and clinical outcome in previously explored patients with PDAC.Results: Between 1995 and 2013, 50 of the 2,062 patients who were surgically explored underwent pancreatic resection following a previous exploration where they were deemed unresectable. The most common reason for unresectability at initial operation was vascular invasion (80%) and a presumed R2 resection. Thirty-seven (74%) patients received neoadjuvant therapy. Neoadjuvant therapy was associated with improved TNM stage (P=0.002), fewer positive lymph nodes (0 vs. 2, P=0.025), and improved median survival (24 vs. 13 months, P=0.044). Compared to R2 resected patients with PDAC who had not previously been explored, re-explored patients had significantly lower pathologic T and N stages (P<0.001) and a longer median survival (19 vs. 10 months, P<0.001). Conclusions:Patients with PDAC deemed unresectable may warrant re-exploration. Treatment with neoadjuvant therapy between operations is associated with improved pathological stage and survival. In this highly selected group of patients, successful resection is associated with improved survival compared to R2 resections.

A review of response in neoadjuvant therapy for exocrine pancreatic cancer

“…Pathologic response generally refers to the analysis of preoperative clinical and postoperative pathologic AJCC/UICC TNM stage. Some studies have attempted to compare outcomes based upon various histopathologic tumor features such as patterns of invasion, grade, and degree of tumor fibrosis 28,42,45,47,56,57 . But, some of these methods have a significant degree of variability as they relate to the effectiveness of NAT.…”

“…All studies were retrospective reviews, with four conducted using prospectively maintained databases. All but three studies reported the postoperative, pathologic TNM stage 28,56,57 . Four studies chose to report the preoperative clinical stage after the administration of NAT 55,58,60,61 .…”

“…These features may be classified either as invasion pattern or grading of the histopathologic response to NAT. The reported patterns of invasion were lymphatic, lymphovascular, microvascular, and perineural, used in five of six studies 28,42,47,56,57 . Only three studies by Chun et al, Macedo et al, and Golan et al reported grades or scores of histopathologic response to NAT.…”

Onco-surgical Strategies in Pancreatic Ductal Adenocarcinoma

“…Thus, pancreatectomies in patients with PDAC initially assessed as unresectable can be safely performed in a group of patients by surgeons with expertise in pancreatic surgery, in referral surgical centers (33)(34)(35)(36). Neoadjuvant therapy prior to reexploration and resection for initially deemed unresectable PDAC has been recently demonstrated to have a survival benefit (38).…”

Duodenopancreatectomia: análise histopatológica de tumores periampulares

“…G astroduodenopancreatectomia (GDPC) é a cirurgia de escolha para tratamento de cânceres periampulares, sejam eles pancreáticos, ampulares, biliares ou duodenais. Apenas 10 a 20% dos pacientes portadores de tumores periampulares ao diagnóstico tem lesões ressecáveis, devido a tumores localmente avançados ou com doença metastática e, desses, a literatura sugere que de 23 a 30% sejam irressecáveis no momento da cirurgia 1 . A sobrevida desses pacientes está associada com o status de ressecção, o estágio da doença e a localização do tumor 2,3 .…”