Surgery after downstaging of Stage IV pancreatic carcinoma: are we facing a new scenario?

Abstract

Background: Metastatic pancreatic carcinoma (mPDAC) has always been an “off-limits” area for pancreatic surgeons, but recent papers consider surgery as an option for synchronous liver oligometastatic patients. We present our retrospective series of resected mPDAC after neoadjuvant chemotherapy (nCT). Methods: All patients resected after downstaging of mPDAC (liver as only metastatic site) were included. Downstaging criteria were disappearance of metastasis and decrease of Ca19.9. Type and duration of nCT, last nCT-surgery interval, histology, morbidity and mortality were recorded. Overall survival (OS) and disease free survival (DFS) were analysed. Results: Twenty four patients out of 535 observed with mPDAC were included. They received Gem alone(21%), Gem+Nab-Paclitaxel(13%) and FOLFIRINOX(66%). Primary tumor size decreased from 30 to 20mm (p:0.01) and so did serum Ca19.9: 596 to 18U/mL (p<0.001). Interval nCT-surgery was 2 months. Mortality was none and postoperative course was uneventful in 34% of cases. Grade B/C pancreatic fistula,bleeding and sepsis occurred respectively in 17/4%, 8% and 12% of cases. Reoperation rate was 4%. R0 resection was achieved in 88% of cases with 17% of complete pathological response. Median harvested nodes was 32 with LNratio of 0.37. OS was 32 months with 21 months of DFS. Conclusion: Patients with mPDAC who fully respond to nCT may be considered for surgery with potential benefit in survival: this is supported by results of our retrospective study that is the largest ever reported.