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ANALYSIS OF SURVIVAL AND PERI-OPERATIVE OUTCOMES IN PERIAMPULLARY CARCINOMA/ PANCREATIC DUCTAL ADENOCARCINOMA FOLLOWING NEOADJUVANT CHEMO/RADIATION AND SURGERY VS. UPFRONT SURGERY
himanshu gupta
*, Rajesh Gupta, Ritambhara Nada, Rakesh Kapoor, Harjeet Singh, Thakur D. Yadav, Surinder S. Rana
GI Surgery, HPB and Liver Transplantation, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
The main idea of neoadjuvant therapy for borderline and locally advanced pancreatic ductal adenocarcinoma is to improve the rate of resection, R0 resection rate, and to improve overall survival.
Objectives: Aim of the study was to analyze survival outcomes in patients following neoadjuvant therapy and surgery vs. upfront surgery. We also looked at other variables like time interval from diagnosis to NACRT initiation and surgery and resectability rate after neoadjuvant therapy in PDAC and periampullary carcinoma. Also perioperative variables including postoperative complications were analysed.
Methods: 80 patients were included in two arms. Neoadjuvant therapies included Gemcitabine + Oxaliplatin, Gemcitanine + Nabpaclitaxel, FOLFIRINOX, Gemcitabine + 36GY 15# RT, depending upon the patient fitness and biochemical parameters. Re-assessment was done after 4 weeks of neoadjuvant therapy and surgery performed between 4-8 weeks.
Results: Preliminary analysis of 47 patients’ data has been done. Amongst 23 patients of upfront surgery arm 19 (82.61%) patients were resectable while 4 (17.39%) were borderline resectable. Out of 24 patients in neoadjuvant arm, 8 (33.3%) patients were borderline resectable, 7 (29.16%) were locally advanced and 6 (25%) patients were resectable and 3 (12.5%) were metastatic, Portal vein involvement was present in 12 (50%) patients of neoadjuvant arm, with 6 (25%) had 90-180 degrees involvement, 3 (12.5%) patients had >180 degrees involvement. Arterial involvement was in 41.67% cases of neoadjuvant arm with 8 (33.3%) patients having >90 degrees of involvement. Amongst these, 3 patients underwent type I portal vein resection (one of which also underwent CHA reconstruction), 2 patients underwent type II and 2 underwent type III resection. 1 patient underwent type III SMV resection, 1 patient underwent type IV portal vein resection. 1 patient underwent classical Whipple’s with supraceliac aorto-common hepatic artery interposition Dacron graft bypass.
Mean overall survival in neoadjuvant arm was 31.82 ± 13.22 months, while mean overall survival in upfront surgery arm was 34.74 ± 7.62 months (p = 0.740) (Fig.1). Mean time interval between diagnosis and start of neoadjuvant treatment was 38.17 days. The mean time interval between completion of neoadjuvant treatment and surgery was 58.36 days. 4 (17.39%) patients in upfront surgery group and 3 (27.28%) in surgery after neoadjuvant group had R1 resection in final histopathological analysis (p = 0.013).
Conclusions: Upfront surgery was associated with better R0 resection rates in resectable PDAC cases, giving importance to requirement of earlier detection and better screening protocols. This study also reiterates the need of neoadjuvant treatment in borderline and locally advanced tumours to downstage them, since aggressive tumour biology of PDAC renders majority of cases unresectable.
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