Operative management of locally advanced pancreatic cancer: analysis of the national cancer database

Abstract

Background: Practice guidelines recommend nonoperative management for patients with locally advanced pancreatic cancer (LAPC). However, surgery has been increasingly incorporated in the multimodality treatment schema for LAPC. Methods: Patients with LAPC (clinical T4) who underwent surgery were identified from the National Cancer Database. Patients were classified based on the receipt of neoadjuvant therapy (NT), neoadjuvant therapy and adjuvant therapy (NT + AT), adjuvant therapy (AT) or surgery alone (SA). Clinicopathologic characteristics and survival outcomes were compared. Results: Surgery was performed on 1,113 patients with LAPC; 325 (29%) received NT, 150 (13%) received NT + AT, 393 (35%) received AT, and 245 (22%) received SA. Margin negative resections were achieved in 378 (80%) of the 475 patients treated with neoadjuvant therapy as compared to 275 (43%) of the 638 patients treated with surgery first (p < 0.001). Patients who received NT or NT + AT had lower pathologic stage as compared to patients who received SA or AT (p < 0.001; Table 1). Ninety-day mortality occurred in 101 (9%) patients, including 25 (5%) of the 475 patients treated with neoadjuvant therapy and 76 (12%) of the 638 patients who had surgery first (p < 0.001). The median overall survival (OS) for all patients was 18 months; for patients who received NT + AT, NT, AT, and SA, the OS was 28, 26, 14, and 7 months, respectively (p < 0.0001). Conclusion: In contrast to recommended guidelines, 57% of patients with LAPC underwent upfront surgical therapy. Utilization of neoadjuvant therapy was associated with pathologic downstaging and an improved survival. Surgery should be utilized cautiously in patients with LAPC and only in the context of a favorable response to neoadjuvant therapy.Table 1Pathologic Stage Based on the American Joint Committee on Cancer, 7th editionTotal n = 1114NT n = 326NT + AT n = 150AT n = 393SA n = 245p-valueT Stage, n (%)<0.001 T04(<1)4(1)0(0)0(0)0(0) T178 (7)55 (17)19(13)4(1)0(0) T260 (5)34 (11)12(8)10 (3)4(2) T3393 (35)180 (55)92 (61)75 (19)46 (19) T4578 (52)52 (16)27(18)304 (77)195 (80)N Stage, n (%)<0.001 N0473 (43)217 (67)65 (43)119(30)72 (29) N1640 (57)108 (33)85 (57)274 (70)173 (71)Anatomic Stage, n (%)<0.001 04(<1)4(1)0(0)0(0)0(0) I109 (10)80 (25)20 (13)7(2)2(1) II417 (37)185 (57)101 (67)84 (21)47 (19) III583 (52)56 (17)29(19)302 (77)196 (80) Open table in a new tab