Abstract
BackgroundEffect of neoadjuvant chemotherapy (NAC) for pancreatic ductal adenocarcinoma (PDAC) has remained under investigation. We investigated its effect from a unique perspective and discussed its application.Patients and methodsWe retrospecively analyzed consecutive 131 PDAC patients who underwent pancreatoduodenectomy and distal pancreatectomy. Clinicopathologic data at surgery and postoperative prognosis were compared between patients who underwent upfront surgery (UFS) (n = 64) and those who received NAC (n = 67), of which 62 (92.5%) received gemcitabine plus S-1 (GS). The GS regimen resulted in about 15% of partial response and 85% of stable disease in a previous study which analyzed a subset of this study subjects.ResultsTumor size was marginally smaller, degree of nodal metastasis and rate of distant metastasis were significantly lower, and pathologic stage was significantly lower in the NAC group than in the UFS group. In contrast, significant differences were not observed in histopathologic features such as vessel and perineural invasions and differentiation grade. Notably, disease-free and overall survivals were similar between the two groups adjusted for the pathologic stage, suggesting that effects of NAC, including macroscopically undetectable ones such as control of micro-metastasis and devitalizing tumor cells, may not be remarkable in the majority of PDAC, at least with respect to the GS regimen.ConclusionsNAC may be useful in downstaging and improving prognosis in a small subset of tumors. However, postoperative prognosis may be determined at the pathologic stage of resected specimen with or without NAC. Therefore, NAC may be applicable to borderline resectable and locally advanced PDAC for enabling surgical resection, but UFS would be desirable for primary resectable PDAC.
Highlights
Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers with an overall 5-year survival rate of only 9% for all stages combined [1]
Postoperative prognosis may be determined at the pathologic stage of resected specimen with or without neoadjuvant chemotherapy (NAC)
NAC may be applicable to borderline resectable and locally advanced pancreatic ductal adenocarcinoma (PDAC) for enabling surgical resection, but upfront surgery (UFS) would be desirable for primary resectable PDAC
Summary
Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers with an overall 5-year survival rate of only 9% for all stages combined [1]. PDAC is classified as resectable, borderline resectable, and locally advanced at the time of initial diagnosis. Resectable PDAC is an indication of upfront surgery (UFS), and neoadjuvant chemotherapy (NAC) is not encouraged [4]. Borderline resectable and locally advanced PDACs are not candidates for UFS and NAC is usually performed to downsize tumors and enable R0 resection (microscopically invasive cancer-free at all margins) [4]. Another study reported that 46 to 61% of locally advanced and unresectable PDAC could undergo resection after NAC with or without other treatments [6]. NAC may improve prognosis in approximately 60% of patients with borderline resectable and locally advanced PDAC by enabling surgical resection. Effect of neoadjuvant chemotherapy (NAC) for pancreatic ductal adenocarcinoma (PDAC) has remained under investigation. We investigated its effect from a unique perspective and discussed its application
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