Extended neoadjuvant chemotherapy (CT) in borderline resectable pancreas cancer (BRPC): Is preoperative chemoradiation (CRT) essential?

Academic Article

Abstract

  • 236 Background: The optimum approach to maximize R0 resection rate in BRPC is unknown. We evaluated an approach in BRPC using extended duration neoadjuvant CT, typically without neoadjuvant CRT to assess R0 resection rate on an "intent to treat"basis. Methods: Patients (pts) were identified from a prospectively-maintained database from 2008-2012. Pts required (1) BRPC per radiographic staging using NCCN/AHPBA criteria, (2) no prior PC therapy (rx) PC, (3) negative staging laparoscopy prior to rx, and (4) all cancer rx at VMMC prior to decision on "downstaging" surgery (S). Pts were initially treated with gemcitabine/docetaxel CT until (a) disease progression, or (b) 24 weeks (wks), before assessment for local rx. Pts with systemic progression and/or inability to complete 24 wks of CT were excluded from local rx; pts with localized cancer at 24 wks judged unlikely to achieve R0 resection were offered 5FU-based CRT then reassessed; all other pts were offered S. Results: Of 70 identified pts, 12/70 (17%) are on initial CT; 58 are fully evaluable. 51/58 pts (88%) completed 24 wks of CT. Response rates to CT were (a) serologic 42/58 (72%) > 50% decline in baseline CA19.9 (median 85%), and (b) radiographic of 47 pts evaluable by RECIST, PR/SD/PD were 60%/32%/8% respectively. 14/58 pts (24%) did not receive local rx (7 intercurrent illness, 7 disease progression). 44/58 pts (76%) were offered local rx- 12/58 (21%) CRT and 32/58 (55%) S. 2 pts receiving CRT later underwent S. CRT. 29 pts (50% total evaluable pts, 85% pts undergoing S) achieved R0 resection;10/29 pts (35%) via en bloc venous resections. 5 pts were inoperable (3 local - subsequently given CRT, 2 systemic). At median f/u of 16 mo, 21/29 (72%) R0 resection pts remain disease free (range 7+-47+mo) along with 4/12 pts (33%) receiving CRT w/o R0 resection (range 12+ -30 mo). 25/58 (43%) fully evaluable pts remain progression free on an "intent to treat" basis. Median OS for all pts is 27 mo (95% CI 15-39 mo); 25/29 R0 resected pts remain alive ( median OS> 20 mo). Conclusions: (1) extended neaoadjuvant CT is a feasible approach in BRPC. (2) Gemcitabine/docetaxel has significant activity in localized PC. (3) Neoadjuvant CRT may not be essential to R0 resection in BRPC.
  • Authors

    Published In

    Digital Object Identifier (doi)

    Pubmed Id

  • 16157959
  • Author List

  • Picozzi VJ; Rocha FG; Rose JB; Traverso LW; Alseidi A; Lin BS; Biehl TA; Ryan JA; Moonka R; Helton S
  • Start Page

  • 236
  • End Page

  • 236
  • Volume

  • 31
  • Issue

  • 4_suppl