Survival Analysis in Patients with Pancreatic Ductal Adenocarcinoma Undergoing Chemoradiotherapy Followed by Surgery According to the International Consensus on the 2017 Definition of Borderline Resectable Cancer

Abstract

Background: The aim of this study was to validate a new definition of borderline resectable pancreatic ductal adenocarcinoma (PDAC) provided by the 2017 international consensus on the basis of three dimensions of anatomical (A), biological (B), and conditional (C) factors, using the data of the patients who had been registered for our institutional protocol of chemoradiotherapy followed by surgery (CRTS) for localized patients with PDAC. Methods: Among 307 consecutive patients pathologically diagnosed with localized PDAC who were enrolled in our CRTS protocol from February 2005 to December 2016, we selected 285 patients who could be re-evaluated after CRT. These 285 patients were classified according to international consensus A definitions as follows: R (resectable; n = 62), BR-PV (borderline resectable, superior mesenteric vein (SMV)/portal vein (PV) involvement alone; n = 27), BR-A (borderline resectable, arterial involvement; n = 50), LA (locally advanced; n = 146). Disease-specific survival (DSS) was analyzed according to A, B (serum CA 19-9 levels and lymph node metastasis diagnosed by computed tomography findings before CRT), and C factors (performance status (PS)) factors. Results: The rates of resection and R0 resection were similar between R (83.9 and 98.0%) and BR-PV (85.2 and 95.5%), but much lower in BR-A (70.0 and 84.8%) and LA (46.6 and 62.5%). DSS evaluated by median survival time (months) showed a similar trend to surgical outcomes: 33.7 in R, 27.3 in BR-PV, 18.9 in BR-A and 19.3 in LA, respectively. DSS in R patients with CA 19-9 levels > 500 U/mL was significantly poorer than in patients with CA 19-9 levels ≤ 500 U/mL, but there were no differences in DSS among BR-PV, BR-A, and LA patients according to CA 19-9 levels. Regarding lymph node metastasis, there was no significant difference in DSS according to each resectability group. DSS in R patients with PS ≥ 2 was significantly worse than in patients with PS 0-1. Conclusions: The international consensus on the definition of BR-PDAC based on three dimensions of A, B, and C is useful and practicable because prognosis of PDAC patients is influenced by anatomical factors as well as biological and conditional factors, which in turn may help to decide treatment strategy.

Prognostic Nutritional Index after Chemoradiotherapy Was the Strongest Prognostic Predictor among Biological and Conditional Factors in Localized Pancreatic Ductal Adenocarcinoma Patients

“…In our study, significant prognostic factors were PS, post-CRT CRP/Alb ratio, post-CRT mGPS, and post-CRT PNI. As we have previously reported, PS was a significant prognostic factor in patients with resectable and UR-LA PDAC [3]. Tas et al [40].…”

“…Between February 2005 and December 2015, 261 consecutive PDAC patients with a cytological or histological diagnosis of localized PDAC determined by 64-slice multidetector computed tomography (MDCT) received our previously reported regimen of chemoradiotherapy followed by surgery (CRTS) [3,16,17,18]. When CRT was completed, we re-evaluated the patient’s condition.…”

“…According to the 2017 international consensus statement [2,3], we assessed pre-CRT and post-CRT anatomical, biological, and conditional factors as well as pre-CRT characteristics (e.g., age, sex, body mass index (BMI), tumor location, and radiological response to CRT) according to the response evaluation criteria in solid tumors (RECIST) version 1.1 classification [25]. Post-CRT factors were evaluated at around four weeks after completion of radiation therapy.…”

“…According to the biological definition, there is a possibility of the extra-pancreatic metastatic disease even in a disease that is potentially resectable based on the anatomical criteria. According to the conditional definition, the patient is at high risk for postoperative morbidity or mortality because of host-related factors, including PS and comorbidities, but has a disease that is anatomically potentially resectable [3].…”

Extended Venous Resections for Borderline Resectable Pancreatic Head Adenocarcinoma—A Retrospective Studies of Nine Cases

“…The outcomes of these cases significantly improved after performing radical surgical procedures such as pancreatoduodenectomy, and the benefits in terms of survival rate were quickly demonstrated in spite of the fact that significant perioperative complications might develop [3][4][5][6]. However, at the time of the initial diagnosis, less than 20% of cases present resectable lesions, as local invasions or distant metastases are frequently encountered [7,8]. When it comes to locally advanced pancreatic head carcinoma, it has been considered that local invasion is the sign of a more aggressive biology of the tumor; however, once the vascular techniques have been widely implemented and extended vascular resections have become more commonly performed, the long-term outcomes came to demonstrate improved rates of survival.…”