Impact of Borderline Resectability in Pancreatic Head Cancer on Patient Survival: Biology Matters According to the New International Consensus Criteria

Abstract

Background International consensus criteria (ICC) have redefined borderline resectability for pancreatic ductal adenocarcinoma (PDAC) according to three dimensions: anatomical (BR-A), biological (BR-B), and conditional (BR-C). The present definition acknowledges that resectability is not just about the anatomic relationship between the tumour and vessels but that biological and conditional dimensions also are important. Methods Patients’ tumours were retrospectively defined borderline resectable according to ICC. The study cohort was grouped into either BR-A or BR-B and compared with patients considered primarily resectable (R). Differences in postoperative complications, pathological reports, overall (OS), and disease-free survival were assessed. Results A total of 345 patients underwent resection for PDAC. By applying ICC in routine preoperative assessment, 30 patients were classified as stage BR-A and 62 patients as stage BR-B. In total, 253 patients were considered R. The cohort did not contain BR-C patients. No differences in postoperative complications were detected. Median OS was significantly shorter in BR-A (15 months) and BR-B (12 months) compared with R (20 months) patients (BR-A vs. R: p = 0.09 and BR-B vs. R: p < 0.001). CA19-9, as the determining factor of BR-B patients, turned out to be an independent prognostic risk factor for OS. Conclusions Preoperative staging defining surgical resectability in PDAC according to ICC is crucial for patient survival. Patients with PDAC BR-B should be considered for multimodal neoadjuvant therapy even if considered anatomically resectable.

Prognostic and predictive value of CA 19-9 in locally advanced pancreatic cancer treated with multiagent induction chemotherapy: results from a prospective, multicenter phase II trial (NEOLAP-AIO-PAK-0113)

“…In contrast to studies performed in resectable pancreatic cancer, 13 , 14 , 27 , 28 , 29 , 30 , 31 baseline CA 19-9 levels (using established cut-off levels such as 500 or 1000 U/ml) were neither prognostic (for OS) nor predictive (for R0 resection) in this prospective LAPC trial after multiagent ICT. The two other prospective randomized trials in LAPC using less intensive ICT with or without CRT reported conflicting results about the prognostic role of baseline CA 19-9, 2 , 32 while other prospective trials in LAPC using multiagent ICT with nab-paclitaxel/gemcitabine 7 or FOLFIRINOX 8 did not analyze the prognostic and predictive role of baseline CA 19-9.…”

Role of imaging in evaluating the response after neoadjuvant treatment for pancreatic ductal adenocarcinoma

“…Inoue et al [ 25 ] reported that NAT with gemcitabine and nab-paclitaxel improved downstaging of the tumor and allowed patient selection. Anger et al [ 26 ] investigated the role of NAT in different types of borderline PDAC according to international consensus criteria. Their results showed that PDAC patients with biological (borderline resectable-B) have a relatively poor prognosis and should be considered for multimodal NAT.…”

Essential updates 2019/2020: Multimodal treatment of localized pancreatic adenocarcinoma: Current topics and updates in survival outcomes and prognostic factors

“…In addition to being prognostic factors, biological and conditional markers are considered crucial in determining BRPDAC surgical outcomes. CA19‐9 level during preoperative treatment has been shown to predict postoperative outcomes 35,49–53 . Barnes et al 54 analyzed 185 BPRDAC patients who received NCRT (FOLFIRINOX or gemcitabine with nab‐paclitaxel) and reported an MST of 46 months in patients whom normalization of CA19‐9 level was achieved after the completion of NCRT.…”