Prognostic Factors After Pancreatectomy for Pancreatic Cancer Initially Metastatic to the Liver

Abstract

Background Resection of initially oligometastatic pancreatic ductal adenocarcinoma (PDAC) following response to first-line chemotherapy is controversial. We herein updated a previous case series to investigate the oncologic outcomes and preoperative factors that could drive the decision-making process. Methods This retrospective analysis was limited to patients with liver-only synchronous metastases who experienced complete regression of the metastatic component and underwent pancreatectomy between October 2008 and July 2020 at two high-volume institutions. Clinical-pathologic variables were captured, and inflammation-based prognostic scores were calculated. Recurrence and survival analyses were performed using standard statistical methods. Results Overall, 52 patients were included. FOLFIRINOX was the most employed chemotherapy regimen (63.5%). Post-treatment tumor size, serum carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) were significantly decreased relative to baseline evaluation. The median time from diagnosis to pancreatectomy was 10.2 months, while the median time from chemotherapy completion to pancreatectomy was 2 months. Major postoperative complications occurred in 26.9% of patients, while postoperative mortality was nil. The median disease-free survival (DFS) and overall survival (OS) from pancreatectomy were 16.5 and 23.0 months, respectively, and the median OS from diagnosis was 37.2 months. At multivariable analysis, vascular resection, operative time, prognostic nutrition index (PNI) and neutrophil-to-lymphocyte ratio (NLR) were associated with OS. Operative time, platelet × neutrophil/lymphocyte count (SII), and PNI were associated with DFS. Conclusions We confirm promising outcomes of selected patients who underwent pancreatectomy following downstaging of liver metastases. The absence of vascular involvement of the primary tumor, good nutritional status, and low inflammatory index scores could be useful to select candidates for resection.

Defining oligometastatic pancreatic cancer: a systematic review and critical synthesis of consensus

“…The majority ( n = 69, 91%) of studies involved one metastatic site, while one study involved metastasis in multiple organs 82 and six studies did not report the number of organs involved. 41 , 45 , 50 , 51 , 53 , 84 Thirty (40%) studies encompassed synchronous metastasis, 29 , 31 , 33 , 34 , 40 , 42 , 43 , 44 , 46 , 47 , 48 , 49 , 51 , 52 , 56 , 60 , 61 , 64 , 69 , 70 , 72 , 73 , 75 , 80 , 83 , 88 , 89 , 90 , 91 , 92 whereas 21 (28%) involved metachronous metastases 13 , 27 , 35 , 37 , 53 , 57 , 58 , 59 , 63 , 65 , 67 , 71 , 74 , 76 , 77 , 79 , 93 , 94 , 95 , 96 and 16 (21%) studies involved both synchronous and metachronous metastases. 2 , 14 , 30 , 32 ...…”

Surgery for Oligometastatic Pancreatic Cancer: Defining Biologic Resectability

“…Frigerio et al found that neutrophil-to-lymphocyte ratio <1.7 was significantly associated with improved overall survival and disease-free survival. 46 Bachellier et al identified that Ca19-9 <500 at diagnosis, R0 resection, and administration of adjuvant chemotherapy were independent prognostic factors for overall survival. 36 These factors are further discussed in subsequent sections.…”

“…Frigerio et al performed a retrospective analysis of 52 patients with liver-only synchronous metastasis, with 73.1% of patients having greater than two liver metastases. 46 All patients received preoperative chemotherapy (63.5% FOLFIRINOX, 36.5% gemcitabine-based) and had complete regression of metastatic lesions before surgical intervention on cross-sectional imaging. Of total patients, 67.3% had normalized Ca19-9 posttreatment.…”

“… 32 However, despite specifying a Ca19-9 decrease >50% relative to baseline as a selection criteria for metastasectomy, within this group, neither Ca19-9 decrease, nor posttreatment normalization were independently associated with survival. 46 Additionally, and perhaps more importantly, approximately 5–7% of the population, belonging to the Le(a−b−) blood group, are unable to express Ca19-9, which compromises its ability to be used as a universal solitary biochemical marker. 76 , 77 …”

“… 83 Frigerio et al found that, in patients who had liver-only synchronous metastases and underwent pancreatectomy after complete regression of the metastases, NLR and SII were associated with overall survival. 46 …”