Prognostic Factors of Survival After Neoadjuvant Treatment and Resection for Initially Unresectable Pancreatic Cancer

Abstract

Objective: To evaluate the impact of clinical and pathological parameters, including resection margin (R) status, on survival in patients undergoing pancreatic surgery after neoadjuvant treatment for initially unresectable pancreatic ductal adenocarcinoma (PDAC). Background: Prognostic factors are well documented for patients with resectable PDAC, but have not been described in detail for patients with initially unresectable PDAC undergoing resection after neoadjuvant therapy. Methods: Prospectively collected data of consecutive patients with initially unresectable pancreatic cancer treated by neoadjuvant treatment and resection were analyzed. The R status was categorized as R0 (tumor-free margin >1 mm), R1 ≤1 mm (tumor-free margin ≤1 mm), and R1 direct (microscopic tumor infiltration at margin). Clinicopathological characteristics and outcomes were compared among these groups and tested for survival prediction. Results: Between January, 2006 and February, 2017, 280 patients with borderline resectable (n = 18), locally advanced (n = 190), or oligometastatic (n = 72) disease underwent tumor resection after neoadjuvant treatment. Median overall survival from the time of surgery was 25.1 months for R0 (n = 82), 15.3 months for R1 ≤1 mm (n = 99), and 16.1 months for R1 direct (n = 99), with 3-year overall survival rates of 35.0%, 20.7%, and 18.5%, respectively (P = 0.0076). The median duration of the neoadjuvant treatment period was 5.1 months. In multivariable analysis, preoperative CA 19–9 levels, lymph node status, metastasis category, and vascular involvement were all significant prognostic factors for overall survival. The R status was not an independent prognostic factor. Conclusions: In patients undergoing resection after neoadjuvant therapy for initially unresectable PDAC, preoperative CA 19–9 levels, lymph node involvement, metastasis category, and vascular involvement, but not the R status, were independent prognostic factors of overall survival.

Benefits of Conversion Surgery after Multimodal Treatment for Unresectable Pancreatic Ductal Adenocarcinoma

“…Metastatic site, decreased CA19-9 level, and performance status are not significant predictive factors for early recurrence. Several articles have reported that decreased CA19-9 levels after multimodal therapy represent a reliable predictive factor for resectability, OS, and DFS [21,[29][30][31][32][33][34][35]. In most patients of the present study, CA19-9 decreased to within normal limits after multimodal treatment.…”

“…However, early recurrence was observed in almost 20% of patients, in line with the findings of Wright et al, who reported that seven out of 23 patients (30.4%) with metastatic PDAC who underwent CS experienced early recurrence. Other studies have also reported early recurrence rates after conversion surgery of approximately 30% [27][28][29]. This would suggest that patients cannot be expected to survive longer than patients who receive non-surgical treatment, and conversion surgery may be harmful to patients because of the high risk of mortality and morbidity associated with extensive pancreatectomy.…”

Surgical indication for and desirable outcomes of conversion surgery in patients with initially unresectable pancreatic ductal adenocarcinoma

“…Eight of them found that decreased CA19‐9 level was a prognostic factor for OS . Three articles found that CA19‐9 response was a prognostic factor for PFS …”

Risk Evaluation of EMT and Inflammation in Metastatic Pancreatic Cancer Cells Following Plasma Treatment

“…Even with surgery in a resectable tumor, the number of R0 resections (no tumor tissue in the respective margins) remains to low [43,44]. Pancreatic cancer has a poor prognosis, and the importance of cell residuals is outlined by the median survival that drops from 25.1 months (for R0) to only 15.3 months with R1 resection [16]. A combination with plasma treatment might become an additive approach to existing surgical and chemotherapeutic strategies to tackle the tumor cell residuals at the surgical margins of the pancreas.…”

“…Disseminated tumor growth induces organ dysfunction and often hinders surgical resection [12][13][14][15]. Especially in pancreatic cancer, the disseminated spread into the peritoneal cavity (peritoneal carcinomatosis) hinders successful cancer therapies [16][17][18][19][20][21][22][23]. Therefore, this type of cancer is a challenging but ideal model to investigate the effect of a novel treatment on cellular detachment and metastatic phenotype.…”