Neoadjuvant therapy in borderline resectable pancreatic ductal adenocarcinoma: A single institution review

Abstract

Objectives: Margin negative (R0) resection is the only known curative therapy for Pancreatic Ductal Adenocarcinoma (PDA), but only 20% of cases are resectable. Neoadjuvant therapy (NATx) in borderline resectable PDA may increase chance for R0 resection and improve overall survival (OS).

Methods: We retrospectively identified 52 patients with borderline resectable PDA based on radiologic findings of clear celiac axis margins and no distant disease with local involvement of the superior mesenteric vein, portal vein, hepatic artery, gastroduodenal artery , or superior mesenteric artery  ≤180 degrees.

Results: Patients were grouped based on NATx and resection history: 17 (33%) NATx and resection (NATxR), 22 (42%) NATx without resection (NATxO), and 13 (25%) upfront resection (UR). Comparison of pathologic vs. clinical stage demonstrated a 41% rate of pathologic downstaging in the NATxR group vs. 77% rate of clinical under staging in the UR group. Median lymph node ratio (number of positive nodes vs. total number of nodes harvested), was lower in the NATxR vs. UR group (0% vs. 12.5%). R0 resection correlated with NATx (NATxR 71% vs. UR 31%; p = .003). Radiation therapy during NATx was associated with an even higher R0 resection rate (82% vs. 25%; p = .05).  Median OS in months was highest in the NATxR group (40.7) vs. UR (22.8), and lowest in unresected patients (13.4) (p = .0002).

Conclusions: NATx in borderline resectable PDA can abate disease progression and increase chance of R0 resection. NATxR and surgical resection leads to the best OS in this analysis.