IN THE NAME OF GOD

Outcomes after resection of locally advanced or borderline resectable pancreatic cancer

after neoadjuvant therapy

The American Journal Of Surgery

By: Z.Jokar

Pancratic ductal adenocarcinoma (PDA)

One of the most deadly malignancies

Surgical resection is necessary

Surgery :

locally advanced 20%

borderline 50%

Compare between :

Neoadjuvant

Upfront resection

Jun.2001 – Dec.2008

LOCALLY ADVANCED UNRESECTABLE

41 (10.1%) BORDERLINE RESECTABLE

403

362 (89.9%) UPFRONT RESECTION

Staging

Abdominal U.S.

Multi detector CT (contrast)/ MRI

Endoscopic U.S.

CA19-9

Pathological confirm

Locally advance unresectable:

• Tumor involvement > 180

• Thrombosis of the portomesentric venous system

Borderline resection:

• Tumor involvement < 180

• Short segment encasement/occlusion of the smv or portal vein amenable to vascular resection and reconstruction

Treatment sequencing & evaluation

External-beam radiotherapy

Chemotherapy (gemcitabine)

Therapeutic response

CT ( 4-6 weeks after end of treatment )

Response evaluation criteria in solid tumors

Pathologic examinations &responses

< 0.05

LNR 0.05 – 0.2

> 0.2

I :COMPLETE-ALMOST COMPLETE REGRESSION/ VIABLE TUMOR CELLS <10%

Grade II :PARTIAL REGRESSION /VIABLE TUMOR CELLS 10-90%

III :NO-MINIMAL REGRESSION /VIABLE TUMOR CELLS 10-90%

Statistical analysis

Median number

IQR

Results

Neoadjuvant:

27(66%) : borderline

41 patients (59 y /21 malel/ 20 female)

14(44%) : locally advanced

10 patients (42%) previous surgical palliation

17 (41.5%) : only chemotherapy

24 (58.5%) : chemoradiotherapy

Ca19-9 : 246.5 u/ml 93 u/ml

Neoadjuvant group had a higher median value of ca19-9 at diagnosis

Median radiologic tumor size : 35 mm 20 mm

Surgical treatment

No statistically differences

The median length of stay of the neoadjuvant group was significantly longer (14 vs 10 d)

Post operative bleeding

Reoperation

Upfront resection 4.1% 3.7%

neoadjuvant 9.8% 13.3%

Adjuvant therapy after surgery

Neoadjuvant : 32(78%)

Upfront resection : 291(82%)

Pathology

Grade I : 3(7%)

Neoadjuvant Grade II : 14(34%)

Grade III : 24(59%)

The medictionan number of evaluated nodes was significantly higher for the upfront group (23 vs 15)

Neoadjuvant: 70.7%

R0 resection

Upfront: 59.7%

R0/R1/R2 Did not differ

R0 margins 35% chemotherapy alone

R0 margins 96% chemoradiotherapy

Survival

In upfront group 16(4.4%) were lost to followup

The median survival time did not differ :

Neoadjuvant : 35 m

Upfront : 37 m

Prognostic factors

Poor survival :

R2 resection

G3/G4 tumors

LNR > 0.2

Body/tail tumors

No adjuvant treathment

Only chemoradiation as neoadjuvant treatment was an independent predictor of survival

Comments

10 patients (42%) previous surgical palliation

76% based on high resolution imaging

Preoperative complications were more in neoadjuvant group (systemic complications/hemorrhage/reoperation)

The median surgical time

No difference The rate of post operative mortality/morbidity

Specific complications

Only the median postoperative length of stay was significantly linger in the neoadjuvant group (14 vs 10d)

Grade I : 3(7%)

Neoadjuvant Grade II : 14(34%)

Grade III : 24(59%)

Grade I : 12%

Chemoradiation Grade II :2%

Grade III :42%

Grade I : 0%

Chemotherapy Grade II :17%

Grade III :82%

Median radiologic tumor size : 35 mm 20 mm

Neoadjuvant :15

The median number of L.N

Upfront :23

Nodal downstaging in neoadjuvant group

R0 margins 35% chemotherapy alone

R0 margins 96% chemoradiotherapy

The median survival time did not differ :

neoadjuvant : 35 m

Upfront : 37 m

Only chemoradiation as neoadjuvant treatment was an independent predictor of survival

Conclusion

Surgical resection after downstaging of locally advanced and borderline resectable pancreatic cancer should be offered to all surgically fit patients without an increased post operative mortality/morbidity

Patients resected after neoadjuvant treatment have at least the same survival rate of patients with resectable disease who undergo primary resection

THANK YOU FOR YOUR ATTENTION