Oncologic Benefits of Neoadjuvant Treatment versus Upfront Surgery in Borderline Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis

Jung, Hye-Sol; Kim, Hyeong Seok; Kang, Jae Seung; Kang, Yoon Hyung; Sohn, Hee Ju; Byun, Yoonhyeong; Han, Youngmin; Yun, Won-Gun; Cho, Young Jae; Lee, Mirang; Kwon, Wooil; Jang, Jin‐Young

doi:10.3390/cancers14184360

Cited by 12 publications

(14 citation statements)

References 40 publications

(154 reference statements)

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“…These results have been further corroborated by several cohort studies, matched-propensity analyses, systematic reviews, and meta-analyses comparing neoadjuvant therapy approaches to up-front surgical approaches, although the studies are limited due to variability in definitions of resectability and treatment regimens 38,41–61 . A meta-analysis of 27 studies and 63,151 patients, including 8461 who received neoadjuvant chemotherapy and 54,690 patients who received up-front surgery, demonstrated that neoadjuvant chemotherapy resulted in a better OS (hazard ratio [HR]: 0.72, 95% CI: 0.69-0.76) and improved R0 resection rate (HR: 0.62, 95% CI: 0.60-0.65) compared with up-front surgery 41 …”

Section: Summary Of Literature Reviewmentioning

confidence: 83%

Executive Summary of the American Radium Society Appropriate Use Criteria for Neoadjuvant Therapy for Nonmetastatic Pancreatic Adenocarcinoma

Jethwa,

Kim,

Berlin

et al. 2023

American Journal of Clinical Oncology

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For patients with locoregionally confined pancreatic ductal adenocarcinoma (PDAC), margin-negative surgical resection is the only known curative treatment; however, the majority of patients are not operable candidates at initial diagnosis. Among patients with resectable disease who undergo surgery alone, the 5-year survival remains poor. Adjuvant therapies, including systemic therapy or chemoradiation, are utilized as they improve locoregional control and overall survival. There has been increasing interest in the use of neoadjuvant therapy to obtain early control of occult metastatic disease, allow local tumor response to facilitate margin-negative resection, and provide a test of time and biology to assist with the selection of candidates most likely to benefit from radical surgical resection. However, limited guidance exists regarding the relative effectiveness of treatment options. In this systematic review, the American Radium Society multidisciplinary gastrointestinal expert panel convened to develop Appropriate Use Criteria evaluating the evidence regarding neoadjuvant treatment for patients with PDAC, including surgery, systemic therapy, and radiotherapy, in terms of oncologic outcomes and quality of life. The evidence was assessed using the Population, Intervention, Comparator, Outcome, and Study (PICOS) design framework and “Preferred Reporting Items for Systematic Reviews and Meta-analyses” 2020 methodology. Eligible studies included phases 2 to 3 trials, meta-analyses, and retrospective analyses published between January 1, 2012 and December 30, 2022 in the Ovid Medline database. A summary of recommendations based on the available literature is outlined to guide practitioners in the management of patients with PDAC.

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Section: Summary Of Literature Reviewmentioning

confidence: 83%

Executive Summary of the American Radium Society Appropriate Use Criteria for Neoadjuvant Therapy for Nonmetastatic Pancreatic Adenocarcinoma

Jethwa,

Kim,

Berlin

et al. 2023

American Journal of Clinical Oncology

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“…Nevertheless, chemotherapy resistance and adverse effects of the anti-cancer drugs may make some patients miss the opportunity of surgery. Studies reported that the overall resection rate was lower in NAT group than upfront surgery group [ 7 , 8 ]. Reliable diagnostic methods are urgently needed to accurately predict the tumor response, as well as to optimal therapeutic selection in patients that are suitable for NAC.…”

Section: Discussionmentioning

confidence: 99%

“…Inadequate tumor response may facilitate tumor progression, obviating the opportunity to completely resect the tumor [ 2 , 6 ]. Several meta-analyses have reported the resection rate was lower in neoadjuvant therapy (NAT) group than upfront surgery group [ 7 , 8 ]. Jung et al [ 7 ] thought that lacking reliable criteria to select patients who are suitable to undergo surgical resection and the low rate to complete chemotherapy cycles due to various adverse effects from anti-cancer agents may be associated with the above results.…”

Section: Introductionmentioning

confidence: 99%

“…Several meta-analyses have reported the resection rate was lower in neoadjuvant therapy (NAT) group than upfront surgery group [ 7 , 8 ]. Jung et al [ 7 ] thought that lacking reliable criteria to select patients who are suitable to undergo surgical resection and the low rate to complete chemotherapy cycles due to various adverse effects from anti-cancer agents may be associated with the above results. In this case, effective radiographic and clinical data are needed to early discriminate the responders from non-responders and help guide the initial therapeutic management.…”

Section: Introductionmentioning

confidence: 99%

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Development and validation of a nomogram model based on pretreatment ultrasound and contrast-enhanced ultrasound to predict the efficacy of neoadjuvant chemotherapy in patients with borderline resectable or locally advanced pancreatic cancer

Yan,

Fu,

Gui

et al. 2024

Cancer Imaging

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Objectives To develop a nomogram using pretreatment ultrasound (US) and contrast-enhanced ultrasound (CEUS) to predict the clinical response of neoadjuvant chemotherapy (NAC) in patients with borderline resectable pancreatic cancer (BRPC) or locally advanced pancreatic cancer (LAPC). Methods A total of 111 patients with pancreatic ductal adenocarcinoma (PDAC) treated with NAC between October 2017 and February 2022 were retrospectively enrolled. The patients were randomly divided (7:3) into training and validation cohorts. The pretreatment US and CEUS features were reviewed. Univariate and multivariate logistic regression analyses were used to determine the independent predictors of clinical response in the training cohort. Then a prediction nomogram model based on the independent predictors was constructed. The area under the curve (AUC), calibration plot, C-index and decision curve analysis (DCA) were used to assess the nomogram’s performance, calibration, discrimination and clinical benefit. Results The multivariate logistic regression analysis showed that the taller-than-wide shape in the longitudinal plane (odds ratio [OR]:0.20, p = 0.01), time from injection of contrast agent to peak enhancement (OR:3.64; p = 0.05) and Peaktumor/ Peaknormal (OR:1.51; p = 0.03) were independent predictors of clinical response to NAC. The predictive nomogram developed based on the above imaging features showed AUCs were 0.852 and 0.854 in the primary and validation cohorts, respectively. Good calibration was achieved in the training datasets, with C-index of 0.852. DCA verified the clinical usefulness of the nomogram. Conclusions The nomogram based on pretreatment US and CEUS can effectively predict the clinical response of NAC in patients with BRPC and LAPC; it may help guide personalized treatment.

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“…According to the Authors, NAT is associated with a longer survival for patients with BRPC, but its broader efficacy in cases of resectable PDAC, and the optimal treatment strategy have yet to be established. In borderline resectable-locally advanced PDAC (BR/LAPC) patients NAT reportedly significantly increases the resection rate, the R0 resection rate, the node-negativity rate, and the median DFS and OS, 12 , 103 - 105 making it the treatment of choice for these patients.…”

Section: Role Of Nat In the Surgical Treatment Of Pdacmentioning

confidence: 99%

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection

Pedrazzoli

2023

Cancer Control

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Vascular resections involving the superior mesenteric and portal veins (SMV-PV), celiac axis (CA), superior mesenteric artery (SMA) and hepatic artery (HA) have multiplied in recent years, raising the resection rate for pancreatic cancer (PDAC) and the related morbidity and mortality rates. While resection is generally accepted for resectable SMV-PV, the usefulness of associated arterial resection in borderline resectable (BRPC) and locally-advanced PDAC (LAPC) is much debated. Careful selection of splenic vein reconstruction is very important to prevent left-sided portal hypertension (LSPH). During distal pancreatectomy (DP), CA and common HA resection is largely accepted, while there is debate on the value of SMA and proper HA resection and reconstruction. Their resection is useless according to several reviews and meta-analyses, and some international societies, although some high-volume centers have reported good results. Short- and long-term reconstructed vessel patency varies with the type of reconstruction, the material used, and the surgeon’s experience. Laparoscopic and robotic pancreaticoduodenectomy and DP are generally accepted if done by surgeons performing at least 10 such procedures annually. The usefulness of associated vascular resection remains highly controversial. Surgeons need to complete numerous minimally-invasive procedures to overcome the learning curve, and prevent an increase in complications and surgical mortality. Higher resectability rates and satisfactory long-term results have been reported after neoadjuvant therapy (NAT) for BRPC and LAPC requiring vascular resection. It is essential to select the most appropriate NAT for a given patient and to assess PDAC resectability preoperatively.

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Oncologic Benefits of Neoadjuvant Treatment versus Upfront Surgery in Borderline Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis

Cited by 12 publications

References 40 publications

Executive Summary of the American Radium Society Appropriate Use Criteria for Neoadjuvant Therapy for Nonmetastatic Pancreatic Adenocarcinoma

Executive Summary of the American Radium Society Appropriate Use Criteria for Neoadjuvant Therapy for Nonmetastatic Pancreatic Adenocarcinoma

Development and validation of a nomogram model based on pretreatment ultrasound and contrast-enhanced ultrasound to predict the efficacy of neoadjuvant chemotherapy in patients with borderline resectable or locally advanced pancreatic cancer

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection

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