Postoperative complications after resection of borderline resectable and locally advanced pancreatic cancer: The impact of neoadjuvant chemotherapy with conventional radiation or stereotactic body radiation therapy

Abstract

Background: The impact of neoadjuvant stereotactic body radiation therapy on postoperative complications for patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma remains unclear. Limited studies have compared neoadjuvant stereotactic body radiation therapy versus conventional chemoradiation therapy. A retrospective study was performed to determine if perioperative complications were different among patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma receiving neoadjuvant stereotactic body radiation therapy or chemoradiation therapy. Methods: Patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma who underwent neoadjuvant chemotherapy with stereotactic body radiation therapy or chemoradiation therapy followed by pancreatectomy at the Johns Hopkins Hospital between 2008 and 2015 were included Predictive factors for severe complications (Clavien grade ≥ III) were assessed by univariate and multivariate analyses. Results: A total of 168 patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma underwent neoadjuvant chemotherapy and RT followed by pancreatectomy. Sixty-one (36%) patients underwent stereotactic body radiation therapy and 107 (64%) patients received chemoradiation therapy. Compared with the chemoradiation therapy cohort, the neoadjuvant stereotactic body radiation therapy cohort was more likely to have locally advanced pancreatic ductal adenocarcinoma (62% vs 43% P = .017) and a require vascular resection (54% vs 37%, P = .027). Multiagent chemotherapy was used more commonly in the stereotactic body radiation therapy cohort (97% vs 75%, P < .001). Postoperative complications (Clavien grade ≥ III 23% vs 28%, P = .471) were similar between stereotactic body radiation therapy and chemoradiation therapy cohort. No significant difference in postoperative bleeding or infection was noted in either group. Conclusion: Compared with chemoradiation therapy, neoadjuvant stereotactic body radiation therapy appears to offer equivalent rates of perioperative complications in patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma despite a greater percentage of locally advanced disease and more complex operative treatment.

Impact of Fiducial Marker Placement Before Stereotactic Body Radiation Therapy on Clinical Outcomes in Patients With Pancreatic Cancer

“…Additionally, approximately 40% of patients were able to eventually undergo surgical resection, regardless of fiducial placement. This is best explained by the use of strong neoadjuvant chemoradiation regimens with SBRT that converted those patients and allowed for subsequent tumor resection (27). One possible explanation for the lack of benefit from fiducial placement might be explained by the higher proportion of patients with locally advanced pancreatic cancer in the fiducial group (46.0% vs 30.4% in the no-fiducial group).…”

Conversion Surgery for Advanced Pancreatic Cancer

“…Several studies investigated morbidity of conversion surgery after NAT for LAPC with overall indecisive results—likely due to heterogeneous treatment algorithms [84]. Larger studies have recently described (major-) morbidity rates between 23% and 59% in borderline and LAPC patients [61,85,86,87]. In a comparative study, overall complications were significantly lower after resection following NAT with FOLFIRINOX compared to a control group of upfront resections (36% vs. 63%) [51].…”

Outcome of Patients with Borderline Resectable Pancreatic Cancer in the Contemporary Era of Neoadjuvant Chemotherapy

“…15 After neoadjuvant chemoradiation treatment, patients with BRPC disease may achieve similar overall survival rates to those with resectable pancreatic cancer following a successful R0 resection. 18,19 However, despite these theoretical advantages, there are some possible disadvantages to using this approach. In particular, there is a perceived risk of disease progression due to the lack of effective systemic therapies, which makes curative resection an impossibility for some patients.…”