Neoadjuvant chemoradiation for non‐metastatic pancreatic cancer increases margin‐negative and node‐negative rates at resection

Berriochoa, Camille A.; Abdel‐Wahab, May; Leyrer, C.M.; Khorana, Alok A.; Walsh, R. Matthew; Kumar, Aryavarta M. S.

doi:10.1111/1751-2980.12551

Cited by 7 publications

(5 citation statements)

References 28 publications

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“…Joint Committee on Cancer defines tumors that involve the celiac axis and superior mesenteric artery (SMA) as T4 and surgically unresectable due to inability to render a negative margin resection with standard pancreatectomy techniques. 1 Consideration of en bloc arterial resection during pancreatectomy had been relatively abandoned for decades due to the significant risk of ischemic and hemorrhagic complications, with attendant morbidity and mortality and historically poor long-term oncologic outcomes, which were initially reported by Fortner in the 1970s. 2 However, there has been renewed interest in en bloc arterial resection for PDAC due to improved response rates and associated survival benefit with modern combination chemotherapeutic regimens with increasing use of total neoadjuvant therapy.…”

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confidence: 99%

En Bloc Celiac Axis Resection for Pancreatic Cancer: Classification of Anatomical Variants Based on Tumor Extent

Truty

Colglazier

Mendes

et al. 2020

Journal of the American College of Surgeons

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BACKGROUND: En bloc celiac axis resection (CAR) for pancreatic cancer is considered increasingly after modern neoadjuvant chemotherapy (NAC). Appleby and distal pancreatectomy with CAR are anatomically inaccurate terms, as tumors can extend beyond celiac axis proper, requiring concurrent resection of the proper hepatic artery and/or superior mesenteric artery. STUDY DESIGN: A 3-level classification for CAR (class 1, 2, or 3) was developed after retrospective review of an arterial resection database describing anatomical variants that dictate pancreatectomy-type, formal arterial revascularization, and gastric preservation. Perioperative and oncologic outcomes were assessed. RESULTS:Of 90 CARs for pancreatic cancer, 89% patients received NAC, 35% requiring chemotherapeutic switch. There were 41 class 1, 33 class 2, and 16 class 3 CARs, with arterial and venous revascularization performed 62% and 66%, respectively. Ninety-day mortality decreased to 4% in the last 50 cases (p ¼ 0.035); major morbidity was unchanged (55%). Any hepatic or gastric ischemia occurred in 20% and 10% patients, respectively, and arterial revascularization was protective. R0 resection rate (88%) was associated with chemoradiation (p ¼ 0.004). Median overall survival was 36.2 months, superior with NAC (8.0 vs. 43.5 months). Predictors of survival after NAC included chemotherapy duration, carbohydrate antigen 19-9 response, pathologic response, and lymph node status. Major pathologic response (p ¼ 0.036) and extended duration NAC (p ¼ 0.007) were independent predictors on multivariate analysis. CONCLUSIONS: Current terminology for CAR inadequately describes all operative variants. Our classification, based on the largest single-center series, allows complex operative planning and standardized reporting across institutions. Extent of arterial involvement determines pancreatectomy type, need for arterial revascularization, and likelihood of gastric preservation. Operative mortality has improved, morbidity remains significant, and survival favorable after extended NAC with associated pathologic responses; given these factors, CAR should only be considered in fit patients with objective NAC responses at specialized centers.

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confidence: 99%

En Bloc Celiac Axis Resection for Pancreatic Cancer: Classification of Anatomical Variants Based on Tumor Extent

Truty

Colglazier

Mendes

et al. 2020

Journal of the American College of Surgeons

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“…Recent RCT showed that clinical tumor staging was down-staged after treatment of gemcitabine-based CRT ( 9 ). Another study showed that neoadjuvant CRT can downstage the PC and eventually increases margin-negative and node-negative rates at resection ( 20 ).…”

Section: Discussionmentioning

confidence: 99%

Is neoadjuvant chemoradiotherapy for pancreatic cancer beneficial: A systematic review and meta-analysis

et al. 2022

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To examine the potential benefits and adverse events of neoadjuvant Chemoradiotherapy (CRT) versus upfront surgery in pancreatic cancer (PC) patients. Extensive librarian-led literature searches were conducted on PubMed, Web-of-Science, Scopus, Google Scholar, the Cochrane Central Library and Embase. The primary outcomes were resectability, adverse events, pathological and survival outcomes. Five studies, including 437 participants, were analyzed. Upfront surgery had a significantly higher resectability among PC patients than neoadjuvant CRT group (Odds ratio = -0.11, 95% CI = -0.19–0.02, P = 0.01). The neoadjuvant CRT group had a comparatively higher Ro resection rate (OR = 3.38, 95% CI = 2.03–5.62, P < 0.01), fewer severe adverse events(OR = 0.56, 95% CI = 0.34–0.92, P = 0.02), lower positive LN rate(OR = 0.18, 95% CI = 0.11-0.31, P < 0.01) and higher 2-year OS(OR = 1.60, 95% CI = 1.02-2.52, P = 0.04) among PC patients than control group. There was no significant difference between neoadjuvant CRT and upfront surgery among PC patients on postoperative complications(OR = 1.49, 95% CI = 0.86-2.57, P = 0.16), metastasis rate(OR = 1.32, 95% CI = 0.42-4.18, P = 0.64) and 1-year OS(OR = 1.30, 95% CI = 0.85-1.98, P = 0.22). This systematic review confirmed the status of neoadjuvant CRT in the PC treatment. The neoadjuvant CRT could increase the R0 resection rate, which was important to the survival and life quality of patients. The specific choice of various neoadjuvant CRT therapy needs to be further studied. Individualized neoadjuvant therapy should be suitable for each patient, and patients with PC are best managed by a multidisciplinary team.

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“…The existing data comparing CRT alone and SCT plus CRT in locally advanced disease is contradictory: in comparing SCT with and without CRT, Hugeut et al found survival benefits in patients who received SCT with CRT, while Hammal et al saw no improvement in survival in patients who received SCT and CRT (15,16). While multiple trials have compared different regimens and combinations of SCT, CRT, or both in resectable and borderline resectable pancreatic adenocarcinoma, there is still more work to elucidate the optimal treatment regimen (17)(18)(19)(20)(21).…”

Section: Discussionmentioning

confidence: 99%

Outcomes of Neoadjuvant Chemoradiation With and Without Systemic Chemotherapy in Resectable and Borderline Resectable Pancreatic Adenocarcinoma

et al. 2020

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Introduction: Neoadjuvant therapy is increasingly being used for localized pancreatic adenocarcinoma. While there is evidence supporting neoadjuvant systemic chemotherapy as well as chemoradiation, more evidence is needed to determine whether systemic chemotherapy with chemoradiation offers benefits over chemoradiation alone. This study compares the outcomes of neoadjuvant chemoradiation therapy with and without systemic chemotherapy in resectable and borderline resectable pancreatic cancers.

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Neoadjuvant chemoradiation for non‐metastatic pancreatic cancer increases margin‐negative and node‐negative rates at resection

Abstract: Neoadjuvant chemoradiation remains a promising approach for non-metastatic pancreatic cancer for improving resectability and pathological and clinical findings. Computed tomography may not fully demonstrate the effectiveness of neoadjuvant treatment.

Cited by 7 publications

References 28 publications

En Bloc Celiac Axis Resection for Pancreatic Cancer: Classification of Anatomical Variants Based on Tumor Extent

En Bloc Celiac Axis Resection for Pancreatic Cancer: Classification of Anatomical Variants Based on Tumor Extent

Is neoadjuvant chemoradiotherapy for pancreatic cancer beneficial: A systematic review and meta-analysis

Outcomes of Neoadjuvant Chemoradiation With and Without Systemic Chemotherapy in Resectable and Borderline Resectable Pancreatic Adenocarcinoma

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