Preoperative Gemcitabine-Based Chemoradiation Therapy for Resectable and Borderline Resectable Pancreatic Cancer

Abstract

Objective: To evaluate the outcome of preoperative gemcitabine-based chemoradiation therapy (CRT) for resectable and borderline resectable pancreatic cancer (PC), with a focus on the differences in surgical outcomes and patterns of recurrence between these 2 categories. Background: Various multimodal treatment strategies have been proposed to improve the surgical outcomes of PC. Preoperative CRT and subsequent surgery is one of the promising strategies for resectable (PC-R) and borderline resectable (PC-BR) PC. Methods: A total of 268 patients with PC-R and PC-BR received preoperative gemcitabine-based CRT. The numbers of PC-R and PC-BR cases were 188 and 80, respectively. We evaluated the following comparisons between patients with PC-R and those with PC-BR: (1) resection rate, (2) rate of margin-negative resection, (3) survival, and (4) pattern of the treatment failure, including local recurrence, peritoneal dissemination, and distant metastasis. Results: The resection rate of patients with PC-R (87%) was higher than that of patients with PC-BR (54%) (P < 0.001). Pathological margin-negative resection was achieved in 99% and 98% of the patients with PC-R and PC-BR, respectively. The 5-year survival rates of the PC-R and PC-BR cases were 57% and 34%, respectively (P = 0.029). Although the 5-year cumulative incidence of local recurrence was comparable in both groups (15% and 13%, respectively; P = 0.508), the 5-year cumulative incidence of peritoneal and distant recurrence was significantly higher in the patients with PC-BR (43 and 76%) than in the patients with PC-R (17% and 43%). Conclusions: In the resected cases, the locoregional control was comparable between patients with PC-R and PC-BR after preoperative CRT. The survival rate for the patients with PC-BR was lower than the rate for those with PC-R due to a higher incidence of peritoneal and distant recurrence in the patients with PC-BR. (UMIN000001804)

Preoperative independent prognostic factors in patients with borderline resectable pancreatic ductal adenocarcinoma following curative resection: the neutrophil-lymphocyte and platelet-lymphocyte ratios

“…Our results suggest that BR-PDAC patients with higher preoperative NLR and/or PLR levels may benefit from high-intensity chemoradiation [36][37][38] and/or systemic and those with an NLR of ≤3 (n = 25) following curative resection (P = 0.002). f A comparison of overall survival in BR-PDAC patients with a preoperative PLR of >225 (n = 8) and those with a PLR of ≤225 (n = 29) following curative resection (P = 0.003).…”

Optimal indication of neoadjuvant chemoradiotherapy for pancreatic cancer

“…There is increasing consensus that patients with BRPC should be treated with neoadjuvant treatment [33][34][35][36]. This is because patients with BRPC have less chance of R0 resection, high risk of local recurrence, and also much poorer prognosis compared to patients with resectable tumors [17,31,37]. However, there are no randomized phase III trials to compare neoadjuvant strategy with surgery-first approach without initial therapy in BRPC.…”

“…Although BRPC may technically be resectable, it has a particularly high risk of margin-positive resection and postoperative recurrence. Furthermore, the prognosis is much worse than that of resectable pancreatic cancer [16,17]. Therefore, recognition of BRPC is important for optimal patient care and evaluation of various new treatment strategies.…”

Diagnosis and Management of Borderline Resectable Pancreatic Adenocarcinoma

“…The International Study Group of Pancreatic Surgery likewise does not support neoadjuvant therapy regimens in borderline resectable pancreatic cancer (BRPC) patients with isolated venous involvement if technical options of resections are possible. 4 Nonetheless, despite a paucity of prospective data to support a standard treatment regimen for borderline resectable pancreatic cancer, neoadjuvant therapy is currently the preferred initial approach in the United States, 25,[43][44][45][46][47][48][49] and was recommended by the expert consensus statement sponsored by the AHPBA, SSAT, and SSO. 41 The rationale for pursuing preoperative treatment for patients with borderline resectable PDAC is similar to that for patients with potentially resectable pancreatic cancer, but a greater emphasis is placed on maximizing the potential for R0 resection.…”