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Upfront versus resection after neoadjuvant chemotherapy for pancreatic adenocarcinomas with venous contact: comparative analysis of operative and survival outcomes

  • Pietro Addeo
    Correspondence
    Reprint requests: Pietro Addeo, MD, MPH, PhD, FACS, Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France 1, Avenue Moliere, 67098, Strasbourg, France.
    Affiliations
    Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France

    ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France
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  • Caterina Cusumano
    Affiliations
    Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
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  • Patrick Dufour
    Affiliations
    Department of Oncology, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
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  • Gerlinde Avérous
    Affiliations
    Department of Pathology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
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  • Philippe Bachellier
    Affiliations
    Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
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Published:February 26, 2022DOI:https://doi.org/10.1016/j.surg.2022.01.011

      Abstract

      Background

      Neoadjuvant treatment before resection for pancreatic adenocarcinoma having contact with the splenomesentericoportal venous axis could improve the results of extended pancreatectomies. We compared the outcomes of upfront (UR) and resection after neoadjuvant chemotherapy (NAC) for pancreatic adenocarcinoma.

      Methods

      We retrospectively reviewed clinical data of patients who underwent pancreaticoduodenectomy with venous resection for pancreatic adenocarcinoma between January 1, 2006, and December 31, 2020. Operative, pathologic, and survival outcomes were compared between upfront and resection after neoadjuvant chemotherapy.

      Results

      Of the 169 patients, 55 patients underwent preoperative chemotherapy and 114 underwent upfront. No differences were found in operative time, morbidity, and mortality between the 2 groups. At pathologic examination, patients who underwent resection after neoadjuvant chemotherapy had a significantly smaller tumor size, higher rate of R0 resection, less lymph node involvement, and a lower rate of pathologic venous invasion (P < .05). The median overall survival was 27.96 months, and the overall survival rates at 1, 3, 5, and 10 years were 82%, 39%, 22%, and 11%, respectively. Multivariate Cox analysis found neoadjuvant treatment (hazard ratio: 0.60; 95% confidence interval: 0.38–0.97; P = .03), and intraoperative transfusion (hazard ratio: 2.25; 95% confidence interval: 1.47–3.46; P = .0002) as independent prognostic factors for overall survival. A dose-dependent effect of perioperative transfusion on overall survival was found (no transfusion, = 2 red blood cells, >2 red blood cells; median overall survival 41.1 months vs 27.01 months vs 19.4 months; P = .0003).

      Conclusion

      Neoadjuvant chemotherapy improves the pathologic and survival outcomes of pancreaticoduodenectomy with venous resection for pancreatic adenocarcinomas. The dose-dependent effect of perioperative transfusion on overall survival warrants further investigation.
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      References

        • Ryan D.P.
        • Hong T.S.
        • Bardeesy N.
        Pancreatic adenocarcinoma.
        N Engl J Med. 2014; 371: 1039-1049
        • Belfiori G.
        • Fiorentini G.
        • Tamburrino D.
        • et al.
        Vascular resection during pancreatectomy for pancreatic head cancer: a technical issue or a prognostic sign?.
        Surgery. 2021; 169: 403-410
        • Addeo P.
        • Velten M.
        • Averous G.
        • et al.
        Prognostic value of venous invasion in resected T3 pancreatic adenocarcinoma: depth of invasion matters.
        Surgery. 2017; 162: 264-274
        • Raptis D.A.
        • Sánchez-Velázquez P.
        • Machairas N.
        • et al.
        Defining benchmark outcomes for pancreatoduodenectomy with portomesenteric venous resection.
        Ann Surg. 2020; 272: 731-737
        • Latenstein A.E.J.
        • Mackay T.M.
        • van der Geest L.G.M.
        • et al.
        Effect of centralization and regionalization of pancreatic surgery on resection rates and survival.
        Br J Surg. 2021; 108: 826-833
        • Malleo G.
        • Maggino L.
        • Marchegiani G.
        • et al.
        Pancreatectomy with venous resection for pT3 head adenocarcinoma: perioperative outcomes, recurrence pattern and prognostic implications of histologically confirmed vascular infiltration.
        Pancreatology. 2017; 17: 847-857
        • Versteijne E.
        • Vogel J.A.
        • Besselink M.G.
        • et al.
        Meta-analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer.
        Br J Surg. 2018; 105: 946-958
        • NCCN Guidelines
        Pancreatic adenocarcinoma. Version 2.2021.
        2021
        • Isaji S.
        • Mizuno S.
        • Windsor J.A.
        • et al.
        International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017.
        Pancreatology. 2018; 18: 2-11
        • Hartwig W.
        • Vollmer C.M.
        • Fingerhut A.
        • et al.
        Extended pancreatectomy in pancreatic ductal adenocarcinoma: definition and consensus of the International Study Group for Pancreatic Surgery (ISGPS).
        Surgery. 2014; 156: 1-14
        • Addeo P.
        • Nappo G.
        • Felli E.
        • Oncioiu C.
        • Faitot F.
        • Bachellier P.
        Management of the splenic vein during a pancreaticoduodenectomy with venous resection for malignancy.
        Updates Surg. 2016; 68: 241-246
        • Addeo P.
        • De Mathelin P.
        • Averous G.
        • et al.
        The left splenorenal venous shunt decreases clinical signs of sinistral portal hypertension associated with splenic vein ligation during pancreaticoduodenectomy with venous resection.
        Surgery. 2020; 168: 267-273
        • Addeo P.
        • Bachellier P.
        Pancreaticoduodenectomy with segmental venous resection: a standardized technique avoiding graft interposition.
        J Gastrointest Surg. 2021; 25: 1925-1931
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Bassi C.
        • Marchegiani G.
        • Dervenis C.
        • et al.
        The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after.
        Surgery. 2017; 161: 584-591
        • Wente M.N.
        • Bassi C.
        • Dervenis C.
        • et al.
        Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS).
        Surgery. 2007; 142: 761-768
        • Wente M.N.
        • Veit J.A.
        • Bassi C.
        • et al.
        Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition.
        Surgery. 2007; 142: 20-25
        • Delpero J.R.
        • Bachellier P.
        • Regenet N.
        • et al.
        Pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a French multicentre prospective evaluation of resection margins in 150 evaluable specimens.
        HPB (Oxford). 2014; 16: 20-33
        • Versteijne E.
        • Suker M.
        • Groothuis K.
        • et al.
        Preoperative chemoradiotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer: results of the Dutch randomized phase III PREOPANC Trial.
        J Clin Oncol. 2020; 38: 1763-1773
        • Pietrasz D.
        • Turrini O.
        • Vendrely V.
        • et al.
        How does chemoradiotherapy following induction folfirinox improve the results in resected borderline or locally advanced pancreatic adenocarcinoma? an AGEO-FRENCH multicentric cohort.
        Ann Surg Oncol. 2019; 26: 109-117
        • Janssen Q.P.
        • van Dam J.L.
        • Bonsing B.A.
        • et al.
        Total neoadjuvant FOLFIRINOX versus neoadjuvant gemcitabine-based chemoradiotherapy and adjuvant gemcitabine for resectable and borderline resectable pancreatic cancer (PREOPANC-2 trial): study protocol for a nationwide multicenter randomized controlled trial.
        BMC Cancer. 2021; 21: 300
        • Nakao A.
        • Kanzaki A.
        • Fujii T.
        • et al.
        Correlation between radiographic classification and pathological grade of portal vein wall invasion in pancreatic head cancer.
        Ann Surg. 2012; 255: 103-108
        • Ferrone C.R.
        • Marchegiani G.
        • Hong T.S.
        • et al.
        Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer.
        Ann Surg. 2015; 261: 12-17
        • Marchegiani G.
        • Andrianello S.
        • Nessi C.
        • et al.
        Neoadjuvant therapy versus upfront resection for pancreatic cancer: the actual spectrum and clinical burden of postoperative complications.
        Ann Surg Oncol. 2018; 25: 626-637
        • Mavros M.N.
        • Xu L.
        • Maqsood H.
        • et al.
        Perioperative blood transfusion and the prognosis of pancreatic cancer surgery: systematic review and meta-analysis.
        Ann Surg Oncol. 2015; 22: 4382-4391
        • Newhook T.E.
        • Prakash L.R.
        • Soliz J.
        • et al.
        Perioperative blood transfusions and survival in resected pancreatic adenocarcinoma patients given multimodality therapy.
        J Surg Oncol. 2021; 124: 1381-1389
        • van Roessel S.
        • van Veldhuisen E.
        • Klompmaker S.
        • et al.
        Evaluation of adjuvant chemotherapy in patients with resected pancreatic cancer after neoadjuvant FOLFIRINOX treatment.
        JAMA Oncol. 2020; 6: 1733-1740