Neoadjuvant Chemotherapy-Chemoradiation for Borderline-Resectable Pancreatic Adenocarcinoma: A UK Tertiary Surgical Oncology Centre Series

Abstract

Background: Patients with borderline-resectable pancreatic ductal adenocarcinoma (BR-PDAC) have historically poor survival, even after curative pancreatic resection and adjuvant chemotherapy. Emerging evidence suggests that neoadjuvant chemoradiation (NCR) improves R0 resection rates in BR-PDAC patients. We evaluated the R0 resection rate, disease-free survival (DFS) and overall survival (OS) in our patients who underwent NCR for BR-PDAC at our institution. Methods: All patients who underwent NCR for BR-PDAC from January 2010 to March 2020 were included in the study. The patients received a variety of NCR regimens during the study period, and in patients with radiological evidence of tumour stability or regression, pancreatic resection was performed. The primary endpoint was the OS, and the secondary endpoints included patient morbidity, the R0 resection rate, histological parameters and the DFS. Results: The study included 29 patients (16 men and 13 women), with a median age of 65 years (range 46–74 years). Of these 29 patients, 17 received FOLFIRINOX and 12 received gemcitabine (GEM)-based NCR regimens. All patients received chemoradiation at the end of chemotherapy (range 45–56 Gy). R0 resection was achieved in 75% of the patients, with a higher rate noted in the FOLFIRINOX group. The median DFS was 22 months for the whole cohort but higher in the FOLFIRINOX group (34 months). The median OS for the cohort was 29 months, with a higher median OS noted for the FOLFIRINOX cohort versus the GEM cohort (42 versus 28 months). Conclusion: NCR, particularly FOLFIRINOX-based treatment, for BR-PDAC results in higher rates of R0 resection and an increased median DFS and OS, supporting its continued use in this patient group.

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection

“…According to the Authors, NAT is associated with a longer survival for patients with BRPC, but its broader efficacy in cases of resectable PDAC, and the optimal treatment strategy have yet to be established. In borderline resectable-locally advanced PDAC (BR/LAPC) patients NAT reportedly significantly increases the resection rate, the R0 resection rate, the node-negativity rate, and the median DFS and OS, 12 , 103 - 105 making it the treatment of choice for these patients.…”

“…Thanks to recently expanded neoadjuvant treatment options and increasing confidence with vascular resections (and arterial resection and reconstruction in particular), many patients previously deemed to have borderline resectable or locally advanced disease underwent successful pancreatic surgery, with or without vascular resection. 12 , 13 This review summarizes and analyzes recent advances in the surgical treatment of PDAC relating to the management of peripancreatic vessels during the resection procedure.…”

Hot topics in pancreatic cancer management

“…In borderline resectable PDACs, higher rates of R0 resections and longer disease-free and overall survival rates have been reported when FOLFIRINOX-based neoadjuvant treatments are used[ 17 ]. Recently, a prospective multicenter phase 2 trial demonstrated promising results when gemcitabine plus nab-paclitaxel chemotherapy were administered before surgery[ 18 ].…”