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Stoop TF, Oba A, Wu YHA, Beaty LE, Colborn KL, Janssen BV, Al-Musawi MH, Franco SR, Sugawara T, Franklin O, Jain A, Saiura A, Sauvanet A, Coppola A, Javed AA, Groot Koerkamp B, Miller BN, Mack CE, Hashimoto D, Caputo D, Kleive D, Sereni E, Belfiori G, Ichida H, van Dam JL, Dembinski J, Akahoshi K, Roberts KJ, Tanaka K, Labori KJ, Falconi M, House MG, Sugimoto M, Tanabe M, Gotohda N, Krohn PS, Burkhart RA, Thakkar RG, Pande R, Dokmak S, Hirano S, Burgdorf SK, Crippa S, van Roessel S, Satoi S, White SA, Hackert T, Nguyen TK, Yamamoto T, Nakamura T, Bachu V, Burns WR, Inoue Y, Takahashi Y, Ushida Y, Aslami ZV, Verbeke CS, Fariña A, He J, Wilmink JW, Messersmith W, Verheij J, Kaplan J, Schulick RD, Besselink MG, Del Chiaro M. Pathological Complete Response in Patients With Resected Pancreatic Adenocarcinoma After Preoperative Chemotherapy. JAMA Netw Open 2024; 7:e2417625. [PMID: 38888920 PMCID: PMC11185983 DOI: 10.1001/jamanetworkopen.2024.17625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 04/18/2024] [Indexed: 06/20/2024] Open
Abstract
Importance Preoperative chemo(radio)therapy is increasingly used in patients with localized pancreatic adenocarcinoma, leading to pathological complete response (pCR) in a small subset of patients. However, multicenter studies with in-depth data about pCR are lacking. Objective To investigate the incidence, outcome, and risk factors of pCR after preoperative chemo(radio)therapy. Design, Setting, and Participants This observational, international, multicenter cohort study assessed all consecutive patients with pathology-proven localized pancreatic adenocarcinoma who underwent resection after 2 or more cycles of chemotherapy (with or without radiotherapy) in 19 centers from 8 countries (January 1, 2010, to December 31, 2018). Data collection was performed from February 1, 2020, to April 30, 2022, and analyses from January 1, 2022, to December 31, 2023. Median follow-up was 19 months. Exposures Preoperative chemotherapy (with or without radiotherapy) followed by resection. Main Outcomes and Measures The incidence of pCR (defined as absence of vital tumor cells in the sampled pancreas specimen after resection), its association with OS from surgery, and factors associated with pCR. Factors associated with overall survival (OS) and pCR were investigated with Cox proportional hazards and logistic regression models, respectively. Results Overall, 1758 patients (mean [SD] age, 64 [9] years; 879 [50.0%] male) were studied. The rate of pCR was 4.8% (n = 85), and pCR was associated with OS (hazard ratio, 0.46; 95% CI, 0.26-0.83). The 1-, 3-, and 5-year OS rates were 95%, 82%, and 63% in patients with pCR vs 80%, 46%, and 30% in patients without pCR, respectively (P < .001). Factors associated with pCR included preoperative multiagent chemotherapy other than (m)FOLFIRINOX ([modified] leucovorin calcium [folinic acid], fluorouracil, irinotecan hydrochloride, and oxaliplatin) (odds ratio [OR], 0.48; 95% CI, 0.26-0.87), preoperative conventional radiotherapy (OR, 2.03; 95% CI, 1.00-4.10), preoperative stereotactic body radiotherapy (OR, 8.91; 95% CI, 4.17-19.05), radiologic response (OR, 13.00; 95% CI, 7.02-24.08), and normal(ized) serum carbohydrate antigen 19-9 after preoperative therapy (OR, 3.76; 95% CI, 1.79-7.89). Conclusions and Relevance This international, retrospective cohort study found that pCR occurred in 4.8% of patients with resected localized pancreatic adenocarcinoma after preoperative chemo(radio)therapy. Although pCR does not reflect cure, it is associated with improved OS, with a doubled 5-year OS of 63% compared with 30% in patients without pCR. Factors associated with pCR related to preoperative chemo(radio)therapy regimens and anatomical and biological disease response features may have implications for treatment strategies that require validation in prospective studies because they may not universally apply to all patients with pancreatic adenocarcinoma.
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Affiliation(s)
- Thomas F. Stoop
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Y. H. Andrew Wu
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - Laurel E. Beaty
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | - Kathryn L. Colborn
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora
| | - Boris V. Janssen
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Pathology, Amsterdam, the Netherlands
| | - Mohammed H. Al-Musawi
- Clinical Trials of Office, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
| | - Salvador Rodriguez Franco
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
| | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Oskar Franklin
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
- Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden
| | - Ajay Jain
- Division of Surgical Oncology, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | | | | | - Ammar A. Javed
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
- Division of Surgical Oncology, Department of Surgery, New York University Medical Center, New York, New York
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Braden N. Miller
- Division of Surgical Oncology, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Claudia E. Mack
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Damiano Caputo
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of General Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Dyre Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Elisabetta Sereni
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Truty, Verona, Italy
| | - Giulio Belfiori
- Pancreatic and Transplant Surgery Unit, San Raffaele Hospital IRCCS, Vita-Salute University, Milano, Italy
| | - Hirofumi Ichida
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Jacob L. van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Keiichi Akahoshi
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keith J. Roberts
- Hepato-Pancreato-Biliary Unit, Department of Surgery, University Hospitals of Birmingham, Birmingham, UK
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University, Faculty of Medicine, Hokkaido, Japan
| | - Knut J. Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Massimo Falconi
- Pancreatic and Transplant Surgery Unit, San Raffaele Hospital IRCCS, Vita-Salute University, Milano, Italy
| | - Michael G. House
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | - Motokazu Sugimoto
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naoto Gotohda
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Paul S. Krohn
- Department of Surgery and Transplantation, Copenhagen University Hospital, Copenhagen, Denmark
| | - Richard A. Burkhart
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - Rohan G. Thakkar
- Department of Hepato-Pancreatico-Biliary and Transplant Surgery, Freeman Hospital, Newcastle University, Newcastle upon Tyne, UK
| | - Rupaly Pande
- Hepato-Pancreato-Biliary Unit, Department of Surgery, University Hospitals of Birmingham, Birmingham, UK
| | - Safi Dokmak
- Department of Surgery, Hôpital Beaujon, Clichy, France
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University, Faculty of Medicine, Hokkaido, Japan
| | - Stefan K. Burgdorf
- Department of Surgery and Transplantation, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stefano Crippa
- Pancreatic and Transplant Surgery Unit, San Raffaele Hospital IRCCS, Vita-Salute University, Milano, Italy
| | - Stijn van Roessel
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Sohei Satoi
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Steven A. White
- Department of Hepato-Pancreatico-Biliary and Transplant Surgery, Freeman Hospital, Newcastle University, Newcastle upon Tyne, UK
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Trang K. Nguyen
- Department of Surgery, Indiana University School of Medicine, Indianapolis
| | | | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University, Faculty of Medicine, Hokkaido, Japan
| | - Vismaya Bachu
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - William R. Burns
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - Yosuke Inoue
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yuta Ushida
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Zohra V. Aslami
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - Caroline S. Verbeke
- Department of Pathology, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Arantza Fariña
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Pathology, Amsterdam, the Netherlands
| | - Jin He
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland
| | - Johanna W. Wilmink
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands
| | - Wells Messersmith
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Joanne Verheij
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Pathology, Amsterdam, the Netherlands
| | - Jeffrey Kaplan
- Department of Pathology, University of Colorado School of Medicine, Aurora
| | - Richard D. Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
| | - Marc G. Besselink
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora
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Stoop TF, Seelen LWF, van 't Land FR, Lutchman KRD, van Dieren S, Lips DJ, van der Harst E, Kazemier G, Patijn GA, de Hingh IH, Wijsman JH, Erdmann JI, Festen S, Groot Koerkamp B, Mieog JSD, den Dulk M, Stommel MWJ, Busch OR, de Wilde RF, de Meijer VE, Te Riele W, Molenaar IQ, van Eijck CHJ, van Santvoort HC, Besselink MG. Nationwide Use and Outcome of Surgery for Locally Advanced Pancreatic Cancer Following Induction Chemotherapy. Ann Surg Oncol 2024; 31:2640-2653. [PMID: 38105377 DOI: 10.1245/s10434-023-14650-6] [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: 06/29/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Several international high-volume centers have reported good outcomes after resection of locally advanced pancreatic cancer (LAPC) following chemo(radio)therapy, but it is unclear how this translates to nationwide clinical practice and outcome. This study aims to assess the nationwide use and outcome of resection of LAPC following induction chemo(radio)therapy. PATIENTS AND METHODS A multicenter retrospective study including all patients who underwent resection for LAPC following chemo(radio)therapy in all 16 Dutch pancreatic surgery centers (2014-2020), registered in the mandatory Dutch Pancreatic Cancer Audit. LAPC is defined as arterial involvement > 90° and/or portomesenteric venous > 270° involvement or occlusion. RESULTS Overall, 142 patients underwent resection for LAPC, of whom 34.5% met the 2022 National Comprehensive Cancer Network criteria. FOLFIRINOX was the most commonly (93.7%) used chemotherapy [median 5 cycles (IQR 4-8)]. Venous and arterial resections were performed in 51.4% and 14.8% of patients. Most resections (73.9%) were performed in high-volume centers (i.e., ≥ 60 pancreatoduodenectomies/year). Overall median volume of LAPC resections/center was 4 (IQR 1-7). In-hospital/30-day major morbidity was 37.3% and 90-day mortality was 4.2%. Median OS from diagnosis was 26 months (95% CI 23-28) and 5-year OS 18%. Surgery in high-volume centers [HR = 0.542 (95% CI 0.318-0.923)], ypN1-2 [HR = 3.141 (95% CI 1.886-5.234)], and major morbidity [HR = 2.031 (95% CI 1.272-3.244)] were associated with OS. CONCLUSIONS Resection of LAPC following chemo(radio)therapy is infrequently performed in the Netherlands, albeit with acceptable morbidity, mortality, and OS. Given these findings, a structured nationwide approach involving international centers of excellence would be needed to improve selection of patients with LAPC for surgical resection following induction therapy.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Freek R van 't Land
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Kishan R D Lutchman
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Geert Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Location Vrije University, Department of Surgery, Amsterdam, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Joris I Erdmann
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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