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RESECTION AFTER MODERN-ERA NEOADJUVANT THERAPY WITHOUT REGRESSION OF ARTERIAL ENCASEMENT IN LOCALLY ADVANCED NON-METASTATIC PANCREATIC CANCER
Michael D. Kluger^*, M. F. Rashid, Beth Schrope, John A. Chabot
New York-Presbyterian Hospital/CUMC, New York, NY

Introduction: Modern-era systemic therapy for locally advanced pancreatic adenocarcinoma can offer median overall and progression free survival of 24 and 15 months, respectively, with 26% of patients being down-staged for resection. We report outcomes of patients undergoing resection without regression from > 180 degrees arterial involvement after current neoadjuvant therapy. Methods: 54 consecutive pts underwent exploration after neoadjuvant therapy for locally advanced NCCN-defined unresectable pancreatic cancer; 4 were excluded after finding metastases. Pts had arterial involvement of the celiac (23) and/or superior mesenteric (17) and/or an extended length of the hepatic (16). Pts were explored with intent of resection and irreversible electroporation for margin extension. Results: 26 male and 24 females, median 65 (IQR:56,69) years of age, received neoadjuvant multi-agent gemcitabine-based (71%) or FOLFIRINOX (29%) for a median of 6 (IQR:6,8) cycles, and SBRT (36%) or IMRT (64%). Median months from initiation of neoadjuvant therapy to surgery was 7.5 (IQR:6.5,8.4). 58% underwent Whipple, 13% distal, and 8% modified Appleby procedures; 26 (52%) patients underwent venous reconstruction, and 41 (82%) had IRE for margin extension. 90-day mortality was 2%. R0 margin was achieved in 76%, and 52% were N0. 1- and 3-year survival from initiation of neoadjuvant therapy was 93% (95%CI 81-97) and 58% (95%CI 38-74), respectively. Median local and distant recurrence free survival was 16.8 (95%CI 5.96-NR) and 8.5 (95%CI 5.11-10.91) months, respectively. Conclusion: With modern-era neoadjuvant therapy, R0 resections can be achieved in a majority of non-metastatic patients with locally advanced, unresectable disease based on cross-sectional imaging. OS and RFS are consistent with past reports of resection after neoadjuvant down-staging. Although possible that IRE extended local RFS, this technology is not expected to affect R status.

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