Neoadjuvant Chemoradiation Impacts the Prognostic Effect of Surgical Margin Status in Pancreatic Adenocarcinoma

Zhang, Eddie; Wang, Lora; Shaikh, Talha; Handorf, Elizabeth; Wong, J.K.; Hoffman, John P.; Reddy, Sanjay S.; Cooper, Harry S.; Cohen, Steven J.; Dotan, Efrat; Meyer, Joshua E.

doi:10.1245/s10434-021-10219-3

Cited by 11 publications

(10 citation statements)

References 23 publications

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“…Of the patients, 76% in the current study underwent R 0 resection based on a 1 mm margin clearance, a rate comparable with previous studies that investigated the R status as a prognostic factor after NAT 23,40,41 . Apart from this comparable distribution of R 0 rates, the impact of strict R 0 resection on oncological outcomes was inconsistent among studies 24,25,41–43 . In a recent large single-center study the revised R status was identified as a predictor of survival based on univariable data but did not reach statistical significance in a multivariable model 21 .…”

Section: Discussionsupporting

confidence: 70%

“…Some of these histopathologic factors have been shown to be independent predictors of survival after NAT as well, including tumor size and lymph node status 21,22 . However, the prognostic importance of the R status after NAT remains controversial, with several studies reporting a prognostic benefit of R 0 resection after NAT, whereas others have not 23–27 . Small sample sizes, inclusion of patients with metastases, nonstandardized pathology protocols, and variations in the NAT regimen have all been cited as reasons for the heterogeneity in these results 28,29 .…”

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confidence: 99%

“…21,22 However, the prognostic importance of the R status after NAT remains controversial, with several studies reporting a prognostic benefit of R0 resection after NAT, whereas others have not. [23][24][25][26][27] Small sample sizes, inclusion of patients with metastases, nonstandardized pathology protocols, and variations in the NAT regimen have all been cited as reasons for the heterogeneity in these results. 28,29 Adding to the controversy, R1 resection after NAT was associated with an increased risk of local recurrence on univariate analysis but not with OS or recurrence-free survival (RFS).…”

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confidence: 99%

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The Revised R Status is an Independent Predictor of Postresection Survival in Pancreatic Cancer After Neoadjuvant Treatment

et al. 2023

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To investigate the oncological outcomes of patients with pancreatic ductal adenocarcinoma (PDAC) who had an R0 or R1 resection based on the revised R status (1 mm) after neoadjuvant therapy (NAT). Background: The revised R status is an independent prognostic factor in upfront-resected PDAC; however, the significance of 1 mm margin clearance after NAT remains controversial. Methods: Patients undergoing pancreatectomy after NAT for PDAC were identified from 2 prospectively maintained databases. Clinicopathological and survival data were analyzed. The primary outcomes were overall survival (OS), recurrence-free survival (RFS), and pattern of recurrence in association with R0 > 1 mm and R1 ≤ 1 mm resections. Results: Three hundred fifty-seven patients with PDAC were included after NAT and subsequent pancreatic resection. Two hundred eight patients (58.3%) received FOLFIRINOX, 41 patients (11.5%) received gemcitabine-based regimens, and 299 individuals (83.8%) received additional radiotherapy. R0 resections were achieved in 272 patients (76.2%) and 85 patients (23.8%) had R1 resections. Median OS after R0 was 41.0 months, compared with 20.6 months after R1 resection (P = 0.002), and even longer after additional adjuvant chemotherapy (R0 44.8 vs R1 20.1 months; P = 0.0032). Median RFS in the R0 subgroup was 17.5 months versus 9.4 months in the R1 subgroup (P < 0.0001). R status was confirmed as an independent predictor for OS (R1 hazard ratio: 1.56, 95% CI: 1.07-2.26) and RFS (R1 hazard ratio: 1.52; 95% CI: 1.14-2.0). In addition, R1 resections were significantly associated with local but not distant recurrence (P < 0.0005). Conclusions: The revised R status is an independent predictor of postresection survival and local recurrence in PDAC after NAT. Achieving R0 resection with a margin of at least 1 mm should be a primary goal in the surgical treatment of PDAC after NAT.

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confidence: 70%

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confidence: 99%

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confidence: 99%

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The Revised R Status is an Independent Predictor of Postresection Survival in Pancreatic Cancer After Neoadjuvant Treatment

et al. 2023

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“…We hypothesize the survival of patients with positive lymph nodes was more likely determined by adjuvant chemotherapy because of biological properties rather than surgical procedures ( 21 ). Modern chemotherapy has proven to be effective and improve survival, even in the setting of an R1 resection ( 22 , 23 ).…”

Section: Discussionmentioning

confidence: 99%

Clinical outcome comparison of laparoscopic radical antegrade modular pancreatosplenectomy vs. laparoscopic distal pancreatosplenectomy for left-sided pancreatic ductal adenocarcinoma surgical resection

Niu

Mou

et al. 2022

Front. Surg.

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BackgroundLaparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS) is a validated surgical treatment for patients with left-sided pancreatic ductal adenocarcinoma (PDAC). In addition, laparoscopic distal pancreatectomy (LDPS) has purported benefits. However, there is a limited analysis comparing the results between LRAMPS and LDPS. Thus, this study aims to compare the short-term and long-term outcomes of patients who underwent LRAMPS and LDPS for PDAC treatment.MethodsPatients with left-sided PDAC that underwent LRAMPS or LDPS from 2015 to 2021 were retrospectively identified. Demographic and clinic pathologic data were collected. Disease-free survival (DFS) and overall survival (OS) probabilities were obtained.ResultsThe number of lymph nodes retrieved was significantly greater in the LRAMPS group than in the LDPS group. Several clinicopathological factors, including CA19-9 levels greater than 37 U/ml, positive lymph nodes, moderate to poor tumor differentiation, and peripancreas fat invasion, were associated with DFS. Moderate with poor tumor differentiation was associated with poor DFS (HR 0.568; 95% CI 0.373–0.921; P = 0.021). Levels of CA19-9 greater than 37 U/ml, CEA levels greater than 5 μg/ml, larger tumor size, positive lymph nodes, moderate with poor tumor differentiation, peripancreas fat invasion, and adjuvant chemotherapy were all associated with OS. LRAMPS nearly improved OS but did not reach statistical significance. Serum carcinoembryonic antigen (CEA) levels greater than 5 ug/ml (HR 1.693; 95% CI 1.200–1.132; P = 0.001), and positive lymph nodes (HR 2.410; 95% CI 1.453–3.995; P = 0.001) were independently associated with poor OS. Treatment with adjuvant chemotherapy was associated with improved OS (HR 0.491; 95% CI 0.248–0.708; P = 0.001).ConclusionsThe LRAMPS procedure achieved comparable results to standard LDPS in terms of postoperative outcomes. Treatment with chemotherapy is important for the prognosis of patients with left-sided pancreatic cancer.

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“…As with all valuable studies, this study by Zhang et al 8 highlights some important unresolved issues. The first is whether NACRT has a continuing effect beyond resection and whether some reported positive margins might have become negative with more time.…”

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confidence: 83%

Is Margin Status Less Prognostic After Neoadjuvant Chemoradiotherapy for Pancreatic Adenocarcinoma?

Windsor

Callery

2021

Ann Surg Oncol

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Neoadjuvant Chemoradiation Impacts the Prognostic Effect of Surgical Margin Status in Pancreatic Adenocarcinoma

Cited by 11 publications

References 23 publications

The Revised R Status is an Independent Predictor of Postresection Survival in Pancreatic Cancer After Neoadjuvant Treatment

The Revised R Status is an Independent Predictor of Postresection Survival in Pancreatic Cancer After Neoadjuvant Treatment

Clinical outcome comparison of laparoscopic radical antegrade modular pancreatosplenectomy vs. laparoscopic distal pancreatosplenectomy for left-sided pancreatic ductal adenocarcinoma surgical resection

Is Margin Status Less Prognostic After Neoadjuvant Chemoradiotherapy for Pancreatic Adenocarcinoma?

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