Optimal Preoperative Multidisciplinary Treatment for Borderline Resectable Pancreatic Cancer

Abstract

Background: For borderline resectable (BR) pancreatic cancer, upfront surgery was standard in the past, but the usefulness of neoadjuvant treatment (NAT) has been reported in recent years. Purpose: The objective of this study was to investigate the optimal neoadjuvant therapy for BR pancreatic cancer invading the portal vein (BR-PV) or abutting major arteries (BR-A). Methods: We retrospectively reviewed 199 patients with BR pancreatic cancer (BR-PV(n = 88), BR-A(n = 111) between 2002 and 2018. Results: 1) In BR-PV patients who underwent upfront surgery (n = 46)/NAT (n = 42), survival was significantly better in the NAT group (P = 0.004). In BR-A patients who underwent upfront surgery (n = 48)/NAT (n = 63), survival was significantly better in the NAT group (P<0.001). 2) In BR-PV patients who underwent FFX/GnP(n = 26) vs GEM/S-1(n = 2) vs GEM/S-1 with radiotherapy (RT)(n = 14), the median survival time (MST) was 32.9/10.0/20.6 months, and the prognosis tended to be better in the FFX/GnP group. The resected cases were 36 (86%). In BR-A patients who underwent FFX/GnP(n = 36) vs GEM/S-1(n = 27), the MST was 35.4/20.4 months, with a significantly better prognosis in the FFX/GnP group (P = 0.022, HR:0.25). The R0 rate tended to be higher with RT. The resected cases were 39 (62%). 3) In 36 BR-PV patients who underwent surgery after NAT, univariate analysis of overall survival revealed that reduction rate of tumor marker (TM)≧90%, preoperative GPS = 0, preoperative high PNI, and preoperative lower CONUT score were significantly associated with better prognosis. In 39 BR-A patients who underwent surgery after NAT, univariate analysis revealed that normalization of TM, preoperative mGPS = 0, and preoperative high PNI were significantly associated with better prognosis. Multivariate analysis showed that normalization of TM was an independent prognostic factor (HR:0.13, P = 0.025). There was no correlation between length of NAT and prognosis. Conclusion: NAT using novel chemotherapy is essential for BR pancreatic cancer. It is suggested that the prognosis may be prolonged by surgery after the TM is greatly reduced, not the length of NAT. Nutritional management during NAT is also important.