Temporal Assessment of Prognostic Factors in Patients With Pancreatic Ductal Adenocarcinoma Undergoing Neoadjuvant Treatment and Resection

Ren, Weizheng; Xourafas, Dimitrios; Ashley, Stanley W.; Clancy, Thomas E.

doi:10.1016/j.jss.2020.07.073

Cited by 9 publications

(20 citation statements)

References 39 publications

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“…However, no differences in surgical morbidity were found between NAT and upfront surgery even after complex vascular reconstructions [ 51 ]. As achieving an R0 resection represents the most important prognostic factor for PaC [ 52 ], the fact that neoadjuvant therapy seems to be able to reduce positive-margin resections is of outmost importance. Versteijne et al [ 45 ] confirmed in a 2018 meta-analysis the increase in R0 resections in both RPC and BRPC after NAT (RPC: NAT 85.5% vs immediate surgery 71.4%; BRPC: NAT 88.6% vs immediate surgery 63.9%).…”

Section: Methodsmentioning

confidence: 99%

Neoadjuvant therapy for pancreatic cancer

2021

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Multimodal treatment including surgery and chemotherapy is considered the gold standard treatment of pancreatic cancer by most guidelines. Neoadjuvant therapy (NAT) has been seen as a possible treatment option for resectable, borderline resectable and locally advanced PaC. The aim of this paper is to offer a state-of-the-art review on neoadjuvant treatments in the setting of pancreatic ductal adenocarcinoma. A systematic literature search was performed using PubMed, Cochrane, Web of Science and Embase databases, in order to identify relevant studies published up to and including July 2021 that reported and analyzed the role of neoadjuvant therapy in the setting of pancreatic carcinoma. Most authors are concordant on the strong role of neoadjuvant therapy in the setting of borderline resectable pancreatic cancers. Recent randomized trials demonstrated improvement of R0 rate and survival after NAT in this setting. Patients with locally advanced cancers may become resectable after NAT, with better results than those obtained with palliative therapies. Even in the setting of resectable cancers, NAT is being evaluated by ongoing randomized trials. Chemotherapy regimens in the setting of NAT and response to NAT are discussed. NAT has an important role in the multimodal treatment of patients with borderline resectable pancreatic cancer. It has a role in patients with locally advanced tumors as it can allow surgical resection in a relevant proportion of patients. For resectable pancreatic cancers, the role of NAT is under evaluation by several randomized trials.

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Section: Methodsmentioning

confidence: 99%

Neoadjuvant therapy for pancreatic cancer

2021

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“…Furthermore, they found that a preoperative CA19-9 of ≥250 U/ml was associated with a marked drop-off in 5-year survival, when compared to <250 U/ml (8.3 vs. 16.8%). Indeed, Ren et al have shown that CA19-9 > 100 U/ ml at diagnosis was independently associated with reduced survival after PD [28]. Thus, perhaps patients with CA19-9 levels >100 U/ml, and certainly >250 U/ml, should be carefully considered for PBD and neoadjuvant chemotherapy (NAC) to downstage the disease burden and improve prognosis, rather than rushing to DS.…”

Section: Survivalmentioning

confidence: 99%

Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer?

Blacker

Lahiri

Phillips

et al. 2021

Expert Review of Gastroenterology & Hepatology

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Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in all patients suffering from obstructive jaundice before pancreatic surgery. The severity of jaundice that mandates PBD has yet to be defined. The evaluated paper examines the impact of PBD on intra-operative, and post-operative outcomes in patients initially presenting with severe obstructive jaundice (bilirubin ≥250 μmol/L). In this key paper evaluation, the impact of PBD versus a direct surgery (DS) approach is discussed. The arguments for and against each approach are considered with regards to drainage associated morbidity and mortality, resection rates, survival and the impact of chemotherapy and malnutrition. Concentrating on resectable head of pancreas tumors, this mini-review aims to scrutinize the authors' recommendations, alongside those of prominent papers in the field.

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“…The criteria for the application of ACT after NAT, beside tolerability, are seldom revealed, but few studies point out it is more often administered in patients with less favorable tumor characteristics on histology, such as regional lymph node metastases, R1 resection, and incomplete pathologic response (27,35,(38)(39)(40). Whether the reduced dose intensity or duration of NAT affects the decision to continue with ACT postoperatively has not been addressed.…”

Section: Administration Frequency and Selection Criteria For Actmentioning

confidence: 99%

“…The results whether ACT brings survival advantage after NAT in resected PC irrespective of resectability state preoperatively are contradictive. Eleven of the studies report no survival benefit (13,21,29,32,41-47), while other fourteen find it beneficial (22,28,30,31,(33)(34)(35)(38)(39)(40)(48)(49)(50)(51). The majority of the studies revealing advantage of ACT do not specify what the resectability status of the patients involved has been and only four of them (22,28,38,48) provide data on the type of ACT administered.…”

Section: Survival Outcome With Act After Nat-matter Of Timing or Total Dose Of Chemotherapymentioning

confidence: 99%

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How to select the most appropriate adjuvant treatment after neoadjuvant treatment and resection for locally advanced pancreatic cancer?

Rangelova

Bratlie

2021

J Gastrointest Oncol

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Adjuvant chemotherapy (ACT) significantly improves survival of patients undergoing upfront surgery for resectable pancreatic cancer. After introducing the concept of neoadjuvant therapy (NAT) with potent chemotherapy regimens, long term survival has been achieved even in patients with borderline and locally advanced pancreatic cancer (BR/LAPC) following radical resection. The observed pathologic tumor response is strongly predictive of survival and provides a unique opportunity to visualize to what extent the cancer has been sensitive to the administered chemotherapy regimen and may potentially give hint how to personalize further oncologic treatment. Current literature provides only limited and heterogeneous data as to whether and what type of ACT is beneficial after NAT and resection for BR/LAPC. Larger studies suggest that ACT may bring survival advantage and should be attempted particularly in node-positive disease and preferably with more potent regimen such as FOLFIRINOX, if tolerable. In case of complete pathologic response, particularly after FOLFIRINOX, it does not seem beneficial to deescalate the treatment during ACT, but whether continuation on the same regimen is worthwhile needs to be further examined. In case of gemcitabine-based treatment as NAT, continuation with more cycles seems to be of value unless tumor biology proves to be too aggressive, with high lymph node ratio. Whether switch to a different regimen should be sought, if tolerability allows it, needs to be further studied. Whether it is the exact treatment sequence (NAT, ACT or both) of the potent chemotherapy regimens like FOLFIRINOX and gemcitabinenab-paclitaxel or the total dose of chemotherapy that has impact on survival in BR/LAPC, is unknown.

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Temporal Assessment of Prognostic Factors in Patients With Pancreatic Ductal Adenocarcinoma Undergoing Neoadjuvant Treatment and Resection

Cited by 9 publications

References 39 publications

Neoadjuvant therapy for pancreatic cancer

Neoadjuvant therapy for pancreatic cancer

Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer?

How to select the most appropriate adjuvant treatment after neoadjuvant treatment and resection for locally advanced pancreatic cancer?

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