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Single Institution Experience With Neoadjuvant Treatment of Borderline Resectable Pancreatic Adenocarcinoma: Achieving R0 Resection With Modern Chemotherapy
Nathan Bolton*, William C. Conway, John S. Bolton
General Surgery, Ochsner, New Orleans, LA
Introduction: Patients with borderline resectable pancreatic cancer (BRPC) are at high risk for early metastasis and margin-positive resection. In this group, neoadjuvant treatment strategies have been adopted to improve patient selection for surgery and increase R0 resection rates. Herein, we report our experience with neoadjuvant chemotherapy (NCT), primarily FOLFIRINOX/FOLFOX followed by 5FU/XRT, for patients with BRPC requiring pancreaticoduodenectomy.
Methods: Data was collected retrospectively on patients with adenocarcinoma of the head of the pancreas from 1/1/2008 to 9/31/2013. Demographics, intraoperative blood loss, ICU stay, total hospital stay, post-operative complications, and rates of R0 resection were examined. Outcomes were compared between NCT and immediate surgery (IS) groups. AHPBA/SSO/SSAT consensus conference definition of "borderline resectable" was used.
Results: 220 patients with PA were analyzed. Of the 220, 30 patients were classified as BRPC and underwent NCT. There was a trend toward increasing use of NCT in more recent years with 3 patients in 2008, and 8 in 2013. In comparison to the IS group, baseline demographics were similar in regards to age (IS 64.89 vs BRPC 65.17 [p=0.89]) and sex (IS: Male 103/192 [53%] vs BRPC: Male 12/30 [40%], p=0.164). There was no difference between the groups in pre-op albumin (IS 3.43 vs BRPC 3.32 [p=0.46]), suggesting similar pre-operative nutritional status despite NCT. Intraoperative blood loss was significantly different between the two groups, with BRPC (mean = 1441cc) losing more blood than their IS counterparts (mean = 686cc). There were no significant differences in measured post-operative complication rates including wound infection (IS 20/190, 10.53% vs BRPC 4/30, 13.33%), anastomotic leak rate (IS 19/190, 10% vs BRPC 1/30, 3.33%), intra-abdominal abscess formation (IS 11/190, 5.79% vs BRPC 2/30, 6.67%), or fistula formation (IS 5/190, 2.63% vs BRPC 2/30, 6.67%). Hospital length of stay (LOS) (IS 13.2 days vs BRPC 16.5 days, p=0.064) and ICU days (IS 1.9 days vs BRPC 1.3 days) were similar between the groups. Perhaps most importantly, the rate of R0 resection did not differ between the groups (C 167/192, 86.9% vs BRPC 27/30, 90%), suggesting that a true oncologic resection is both possible and expected.
Conclusions: In BRPC patients who undergo NCT with modern chemotherapies, R0 resection, hospital and ICU stay, and postoperative complications did not differ from there IS counterparts despite later presentation and/or more aggressive tumor biology. The increase in intraoperative blood loss in the BRPC group likely reflects the increased complexity of the vascular resections necessary to remove these tumors with negative margins. The current rate of R0 resection, and noted radiographic responses, indicate superior efficacy of newer regimens in the neoadjuvant setting.
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