IN THE NAME OF GOD. Outcomes after resection of locally advanced or borderline resectable pancreatic...
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![Page 1: IN THE NAME OF GOD. Outcomes after resection of locally advanced or borderline resectable pancreatic cancer after neoadjuvant therapy The American Journal.](https://reader036.fdocuments.in/reader036/viewer/2022070308/551c21b7550346a84f8b5bc1/html5/thumbnails/1.jpg)
IN THE NAME OF GOD
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Outcomes after resection of locally advanced or borderline resectable pancreatic cancer
after neoadjuvant therapy
The American Journal Of Surgery
By: Z.Jokar
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Pancratic ductal adenocarcinoma (PDA)
One of the most deadly malignancies
Surgical resection is necessary
Surgery :
locally advanced 20%
borderline 50%
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Compare between :
Neoadjuvant
Upfront resection
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Jun.2001 – Dec.2008
LOCALLY ADVANCED UNRESECTABLE
41 (10.1%) BORDERLINE RESECTABLE
403
362 (89.9%) UPFRONT RESECTION
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Staging
Abdominal U.S.
Multi detector CT (contrast)/ MRI
Endoscopic U.S.
CA19-9
Pathological confirm
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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
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Treatment sequencing & evaluation
External-beam radiotherapy
Chemotherapy (gemcitabine)
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Therapeutic response
CT ( 4-6 weeks after end of treatment )
Response evaluation criteria in solid tumors
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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%
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Statistical analysis
Median number
IQR
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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
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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
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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%
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Adjuvant therapy after surgery
Neoadjuvant : 32(78%)
Upfront resection : 291(82%)
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Pathology
Grade I : 3(7%)
Neoadjuvant Grade II : 14(34%)
Grade III : 24(59%)
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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
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Survival
In upfront group 16(4.4%) were lost to followup
The median survival time did not differ :
Neoadjuvant : 35 m
Upfront : 37 m
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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
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Comments
10 patients (42%) previous surgical palliation
76% based on high resolution imaging
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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)
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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%
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Median radiologic tumor size : 35 mm 20 mm
Neoadjuvant :15
The median number of L.N
Upfront :23
Nodal downstaging in neoadjuvant group
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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
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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
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THANK YOU FOR YOUR ATTENTION