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Does Radiologic Response Correlate to Pathologic Response in Patients Undergoing Neoadjuvant Therapy for Pancreatic Malignancy?
Brent T. Xia*1, Young Kim1, Baojin Fu2, Jiang Wang2, Vikrom K. Dhar1, Nick C. Levinsky1, Dennis J. Hanseman1, David Habib1, Megan Stevenson1, Gregory C. Wilson1, Jeffrey M. Sutton1, Ali Al Humaidi1, Daniel E. Abbott1, Syed Ahmad1
1Surgery, University of Cincinnati, Cincinnati, OH; 2Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, OH
Introduction: In the modern era, neoadjuvant therapy is increasingly being utilized for patients with pancreatic malignancy, with radiographic response serving as the primary driver to determine if patients should be offered surgical intervention. We sought to determine whether there was any correlation between radiographic and pathologic response rates, and their influence on patient outcomes.
Methods: Between 2005 to 2015, 40 patients underwent neoadjuvant therapy followed by pancreaticoduodenectomy for pancreatic cancer. Perioperative imaging and pathology were reviewed. Radiographic response post-neoadjuvant therapy and pathologic response were graded according to RECIST and Evans’ criteria, respectively. Evans grade IIB was designated partial response.
Results: There were 21 male and 19 female patients, with a median age of 63 years. The proportion of patients that harbored borderline, locally advanced, and resectable diseases were 62.5% (n=25), 32.5% (n=13), and 5% (n=2), respectively. Preoperatively, 47.5% of patients underwent chemotherapy alone and 52.5% underwent chemotherapy/chemoradiotherapy. The most common chemotherapy regimens were single-agent gemcitabine (n=8), gemcitabine/nab-paclitaxel (n=14), and gemcitabine/erlotinib (n=7). Altogether, 67.5% (n=27) of patients had stable disease (SD), and 30% (n=12) demonstrated a partial response (PR) based on preoperative imaging (RECIST criteria). The remainder (n=1) had progressive disease (PD). Of patients with SD on imaging, 25.9% (n=7) had Evans grade IIB or greater pathologic response. Among patients with vascular involvement and without radiographic response, 76.5% (n=13) achieved a R0 resection. Pathologically, 67.5% (n=27) of patients had Evans grade I-IIA response, 27.5% (n=11) had a grade IIB-III response, and 5% (n=2) had a grade IV complete response. The majority of patients who achieved a partial or complete pathologic response underwent both chemotherapy and chemoradiotherapy.
Conclusions: Our data indicates that (1) approximately one-fourth of patients who did not have a RECIST response on imaging had a grade IIB or greater pathologic response, (2) in the absence of distal disease, lack of down-staging following neoadjuvant therapy should not be utilized to determine resectability, and (3) pathologic response is most likely to occur when patients receive both chemotherapy and chemoradiotherapy.
Distribution of Radiographic and Pathologic responses
| Radiographic Response | Pathologic Response | | Partial Response (12) | Minimal: 6 (50%)
Partial: 6 (50%) | | Stable Disease (27) | Minimal: 20 (74.1%)
Partial: 5 (18.5%)
Complete: 2 (7.4%) | | Progressive Disease (1) | Minimal: 1 (100%) |
Radiographic response per RECIST guideline (version 1.1). Pathologic response per Evans' Grade: Minimal (grade I-IIA), Moderate (grade IIB-III), Complete (grade IV).
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