Abstract
Background
Neoadjuvant chemotherapy may benefit patients with pancreatic ductal adenocarcinoma
with resectable and borderline disease. Inappropriate use of neoadjuvant therapy,
however, may lead to the loss of therapeutic opportunities. Until an effective prediction
model of individual drug sensitivity is established, no accurate model exists to help
surgeons decide on the appropriate use of neoadjuvant chemotherapy. We hypothesized
that early recurrence in patients undergoing upfront, early resection may be an indication
for neoadjuvant chemotherapy. Therefore, we aimed to use preoperative clinical parameters
to establish a model of early recurrence to select patients at high risk for neoadjuvant
chemotherapy.
Methods
Patients who underwent resection for pancreatic ductal adenocarcinoma between January
2014 and November 2017 were analyzed retrospectively. After the minimum P-value approach, the patients were divided into three groups: early recurrence, middle
recurrence, and late/non-recurrence. Preoperative clinicopathologic factors that could
predict early recurrence were included in a Cox proportional hazards regression model
for univariate and multivariate analyses. The factors related to early recurrence
were included to establish nomogram and decision tree models, which were then validated
in 68 patients.
Results
We found that 235 (72.5%) of 324 patients had recurrence with a median recurrence-free
survival of 210 days. The early recurrence, middle recurrence, and late/non-recurrence
groups differed in preoperative carbohydrate antigen 19-9 and carcinoembryonic antigen
levels, “resectability” on cross-sectional imaging, resection requiring a vascular
resection, T stage, tumor size, and adjuvant chemotherapy. The best cutoff value of
early recurrence was the first 162 days postoperatively. Univariate and multivariate
analyses showed that selected preoperative chief complaints, lymph node enlargement
and resectability on cross-sectional imaging, preoperative carbohydrate antigen 19-9
levels >210 kU/L, and a neutrophil/lymphocyte ratio >4.2 were independent predictors
for early recurrence.
Conclusion
We have successfully built a prediction model of early recurrence of patients with
pancreatic ductal adenocarcinoma with the optimal cutoff early-recurrence value of
162 days. Our nomogram and decision tree models may be used to select those at high
risk for early recurrence to guide preoperative decision-making concerning the use
of neoadjuvant therapy in those patients who have “resectable” disease and not only
the more classic criteria of borderline resectability.
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Article info
Publication history
Published online: April 19, 2020
Accepted:
February 7,
2020
Footnotes
Shi-wei Guo, Jing Shen, and Jun-hui Gao are co-first authors who have contributed equally to this article.
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
