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Theijse RT, Stoop TF, Leenart PD, Lutchman KRD, Erdmann JI, Daams F, Zonderhuis BM, Festen S, Swijnenburg RJ, van Gulik TM, Schoorlemmer A, Sterk ALA, van Dieren S, Fariña A, Voermans RP, Wilmink JW, Kazemier G, Busch OR, Besselink MG. Surgery for Locally Advanced Pancreatic Cancer Following Induction Chemotherapy: A Single-Center Experience. Ann Surg Oncol 2024; 31:6180-6192. [PMID: 38954094 PMCID: PMC11300483 DOI: 10.1245/s10434-024-15591-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND The use of surgery in patients with locally advanced pancreatic cancer (LAPC) following induction chemotherapy is increasing. However, most series do not report on the total cohort of patients undergoing surgical exploration; therefore, this single-center study investigates outcomes among all consecutive patients with LAPC who underwent surgical exploration. METHODS We conducted a retrospective, single-center analysis including all consecutive patients with LAPC (Dutch Pancreatic Cancer Group criteria) who underwent surgical exploration with curative intent (January 2014-June 2023) after induction therapy. Primary outcomes were resection rate and overall survival (OS) from the time of diagnosis. RESULTS Overall, 127 patients underwent surgical exploration for LAPC, whereby 100 patients (78.7%) underwent resection and 27 patients (21.3%) underwent a non-therapeutic laparotomy due to the extent of vascular involvement (n = 11, 8.7%) or occult metastases (n = 16, 12.6%). The overall in-hospital/30-day mortality rate was 0.8% and major morbidity was 31.3% (in patients after resection: 1.0% and 33.3%, respectively). The overall 90-day mortality rate was 5.5%, which included 3.1% mortality due to disease progression. Resection was associated with longer median OS {29 months (95% confidence interval [CI] 26-43) vs. 17 months (95% CI 11-26); p < 0.001} compared with patients undergoing non-therapeutic laparotomy, with corresponding 5-year OS rates of 28.4% and 7.7%. In Cox proportional hazard regression analysis, only pancreatic body/tail tumors independently predicted OS (hazard ratio 1.788 [95% CI 1.042-3.068]). CONCLUSION This single-center series found a resection rate of 78.7% in patients with LAPC selected for surgical exploration, with a low risk of mortality and morbidity in all explored patients and a 5-year OS rate after resection of 28.4%.
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Affiliation(s)
- Rutger T Theijse
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Thomas F Stoop
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Philip D Leenart
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Kishan R D Lutchman
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Joris I Erdmann
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Freek Daams
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Babs M Zonderhuis
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Annuska Schoorlemmer
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - André L A Sterk
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Arantza Fariña
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier P Voermans
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Geert Kazemier
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, 1081 HV, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, 1081 HV, Amsterdam, The Netherlands.
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Stoop TF, Theijse RT, Seelen LWF, Groot Koerkamp B, van Eijck CHJ, Wolfgang CL, van Tienhoven G, van Santvoort HC, Molenaar IQ, Wilmink JW, Del Chiaro M, Katz MHG, Hackert T, Besselink MG. Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer. Nat Rev Gastroenterol Hepatol 2024; 21:101-124. [PMID: 38036745 DOI: 10.1038/s41575-023-00856-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 12/02/2023]
Abstract
Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rutger T Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Christopher L Wolfgang
- Division of Surgical Oncology, Department of Surgery, New York University Medical Center, New York City, NY, USA
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Radiation Oncology, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands.
- Cancer Center Amsterdam, Amsterdam, Netherlands.
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Pedrazzoli S. Currently Debated Topics on Surgical Treatment of Pancreatic Ductal Adenocarcinoma: A Narrative Review on Surgical Treatment of Borderline Resectable, Locally Advanced, and Synchronous or Metachronous Oligometastatic Tumor. J Clin Med 2023; 12:6461. [PMID: 37892599 PMCID: PMC10607532 DOI: 10.3390/jcm12206461] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Previously considered inoperable patients (borderline resectable, locally advanced, synchronous oligometastatic or metachronous pancreatic adenocarcinoma (PDAC)) are starting to become resectable thanks to advances in chemo/radiotherapy and the reduction in operative mortality. METHODS This narrative review presents a chosen literature selection, giving a picture of the current state of treatment of these patients. RESULTS Neoadjuvant therapy (NAT) is generally recognized as the treatment of choice before surgery. However, despite the increased efficacy, the best pathological response is still limited to 10.9-27.9% of patients. There are still limited data on the selection of possible NAT responders and how to diagnose non-responders early. Multidetector computed tomography has high sensitivity and low specificity in evaluating resectability after NAT, limiting the resection rate of resectable patients. Ca 19-9 and Positron emission tomography are giving promising results. The prediction of early recurrence after a radical resection of synchronous or metachronous metastatic PDAC, thus identifying patients with poor prognosis and saving them from a resection of little benefit, is still ongoing, although some promising data are available. CONCLUSION In conclusion, high-level evidence demonstrating the benefit of the surgical treatment of such patients is still lacking and should not be performed outside of high-volume centers with interdisciplinary teams of surgeons and oncologists.
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Igarashi T, Yamada S, Hoshino Y, Murotani K, Baba H, Takami H, Yoshioka I, Shibuya K, Kodera Y, Fujii T. Prognostic factors in conversion surgery following nab-paclitaxel with gemcitabine and subsequent chemoradiotherapy for unresectable locally advanced pancreatic cancer: Results of a dual-center study. Ann Gastroenterol Surg 2022; 7:157-166. [PMID: 36643365 PMCID: PMC9831906 DOI: 10.1002/ags3.12613] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/05/2022] [Indexed: 01/18/2023] Open
Abstract
Background In pancreatic ductal adenocarcinoma (PDAC), only radical surgery improves long-term survival. We focused on surgical outcome after induction gemcitabine along with nab-paclitaxel (GnP) and subsequent chemoradiotherapy (CRT) with S-1 administration for unresectable locally advanced (UR-LA) PDAC. Methods We retrospectively analyzed 144 patients with UR-LA PDAC between 2014 and 2020. The first-line regimen of induction chemotherapy was GnP for 125 of the 144 patients. Of the 125 patients who received GnP, 41 who underwent radical resection after additional preoperative CRT were enrolled. We evaluated the prognostic factors for this treatment strategy. Results The median length of preoperative GnP was 8.8 months, and 30 (73%) patients had normalized CA19-9 levels. R0 resection was achieved in 36 (88%) patients. Postoperative major complications of ≥Clavien-Dindo grade IIIa developed in 16 (39%) patients. With a median follow-up of 35.2 months, 14 (34%) patients developed distant metastasis postoperatively. Using the Kaplan-Meier method, prognostic analysis of the 41 cases revealed the 3-y overall survival rate (OS) was 77.4% and the 5-y OS was 58.6%. In univariate analysis, length of preoperative GnP (≥8 months), CA19-9 normalization, and good nutritional status at operation (prognostic nutritional index ≥41.7) were significantly associated with favorable prognosis. Multivariate analysis revealed CA19-9 normalization (hazard ratio [HR] 0.23; P = .032) and prognostic nutritional index ≥41.7 (HR 0.05; P = .021) were independent prognostic factors. Conclusion For surgical outcome after induction GnP and subsequent CRT for UR-LA PDAC, CA19-9 normalization and maintenance of good nutritional status during treatment until surgery were important for prolonged prognosis.
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Affiliation(s)
- Takamichi Igarashi
- Department of Surgery and Science, Faculty of Medicine, Academic AssemblyUniversity of ToyamaToyamaJapan
| | - Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II)Nagoya University Graduate School of MedicineNagoyaJapan
| | - Yui Hoshino
- Department of Surgery and Science, Faculty of Medicine, Academic AssemblyUniversity of ToyamaToyamaJapan
| | - Kenta Murotani
- Biostatistics Center, Graduate School of MedicineKurume UniversityKurumeJapan
| | - Hayato Baba
- Department of Surgery and Science, Faculty of Medicine, Academic AssemblyUniversity of ToyamaToyamaJapan
| | - Hideki Takami
- Department of Gastroenterological Surgery (Surgery II)Nagoya University Graduate School of MedicineNagoyaJapan
| | - Isaku Yoshioka
- Department of Surgery and Science, Faculty of Medicine, Academic AssemblyUniversity of ToyamaToyamaJapan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of Medicine, Academic AssemblyUniversity of ToyamaToyamaJapan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II)Nagoya University Graduate School of MedicineNagoyaJapan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic AssemblyUniversity of ToyamaToyamaJapan
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