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