Outcome of Patients with Borderline Resectable Pancreatic Cancer in the Contemporary Era of Neoadjuvant Chemotherapy

Abstract

Introduction Approximately, 20% of patients with pancreatic ductal adenocarcinoma have resectable disease at diagnosis. Given improvements in locoregional and systemic therapies, some patients with borderline resectable pancreatic cancer (BRPC) can now undergo successful resection. The outcomes of patients with BRPC after neoadjuvant therapy remain unclear. Methods A prospectively maintained single-institution database was utilized to identify patients with BRPC who were managed at the Johns Hopkins Pancreas Multidisciplinary Clinic (PMDC) between 2013 and 2016. BRPC was defined as any tumor that presented with radiographic evidence of the involvement of the portal vein (PV) or superior mesenteric vein (SMV) that was deemed to be technically resectable (with or without the need for reconstruction), or the abutment (< 180° involvement) of the common hepatic artery (CHA) or superior mesenteric artery (SMA), in the absence of involvement of the celiac axis (CA). We collected data on treatment, the course of the disease, resection rate, and survival. Results Of the 866 patients evaluated at the PMDC during the study period, 151 (17.5%) were staged as BRPC. Ninety-six patients (63.6%) underwent resection. Neoadjuvant chemotherapy was administered to 142 patients (94.0%), while 78 patients (51.7%) received radiation therapy in the neoadjuvant setting. The median overall survival from the date of diagnosis, of resected BRPC patients, was 28.8 months compared to 14.5 months in those who did not (p < 0.001). Factors associated with increased chance of surgical resection included lower ECOG performance status (p = 0.011) and neck location of the tumor (p = 0.001). Forty-seven patients with BRPC (31.1%) demonstrated progression of disease; surgical resection was attempted and aborted in 12 patients (7.9%). Eight patients (5.3%) were unable to tolerate chemotherapy; six had disease progression and two did not want to pursue surgery. Lastly, four patients (3.3%) were conditionally unresectable due to medical comorbidities at the time of diagnosis due to comorbidities and failed to improve their status and subsequently had progression of the disease. Conclusion After initial management, 31.1% of patients with BRPC have progression of disease, while 63.6% of all patients successfully undergo resection, which was associated with improved survival. Factors associated with increased likelihood of surgical resection include lower ECOG performance status and tumor location in the neck.

The Role of Radiological Parameters in Assessing Response to Neoadjuvant Therapy in Borderline Resectable Pancreatic Cancer

“…Statistically significant improvement in terms of OS was attained for resected BRPC (32 months) in contrast to unresected patients (17 months). This is in agreement with the recent meta-analysis on BRPC subjects that registered OS of 27.4 months vs. 12.9 months in resectable and unresectable cases respectively 15 . Other series reported lower survival rates 12,16 .…”

Outcomes of Primary Chemotherapy for Borderline Resectable and Locally Advanced Pancreatic Ductal Adenocarcinoma

“…[12][13][14] Furthermore, a limitation of most studies is the inability to determine how many patients receiving primary chemotherapy never qualified for surgery because of treatment discontinuation, disease progression, or death. [15][16][17][18][19][20][21][22] This prospective cohort study enrolled consecutive patients with new diagnoses of BR and LA PDAC. The analysis is limited to a recent 3-year period, with the aim to evaluate pragmatically the rate of chemotherapy receipt, the treatment compliance, the rate of surgery, and survival outcomes.…”

Prognostic value of adjacent organ resection in patients with left‐sided pancreatic ductal adenocarcinoma following distal pancreatectomy

“…Neoadjuvant treatment, including chemotherapy or chemoradiation for borderline resectable and locally unresectable pancreatic cancer offers several advantages including: the potential to downstage tumors to enable surgical resection and better prognosis. Therefore, current consensus guidelines have recommended the use of neoadjuvant therapy for these BRPC . However, there are few studies on surgical outcomes and prognosis of PDAC with adjacent organ infiltration.…”

“…There are several reports on DP with portal vein/superior mesenteric vein resection (PV/SMVR), which is usually performed for borderline resectable pancreatic cancer (BRPC) according to the National Comprehensive Cancer Network (NCCN) guidelines , and they show a worse oncological outcome than DP without vessel resection . Although the BRPC had poor prognosis, there have been several reports that the development and adoption of neoadjuvant chemotherapy for BRPC, which has increased the resection rate, margin‐negative rate and overall survival .…”