Anatomic Criteria Determine Resectability in Locally Advanced Pancreatic Cancer

Introduction: The introduction of neoadjuvant systemic treatment has facilitated potential resection with curative intent in selected locally advanced pancreatic cancer (LAPC) patients with excellent outcomes. Nevertheless, a lack of consensus on LAPC management remains. We sought to describe outcomes of patients with LAPC and objectively define the multidisciplinary selection process for operative exploration based on anatomical factors. Methods: Consecutive patients with LAPC were evaluated for pancreatic surgery in the multidisciplinary clinic of a high-volume institution, between 2013 and 2018. Prospective stratification (LAPC-1, LAPC-2, and LAPC-3), based on the involvement of regional anatomical structures, was performed at the time of presentation prior to the initiation of treatment. Resection rates and patient outcomes were evaluated and correlated with the initial anatomic stratification system. Results: Overall, 415 patients with LAPC were included in the study, of whom 84 (20%) were successfully resected, with a median overall survival of 35.3 months. The likelihood of operative exploration was associated with the pretreatment anatomic LAPC score, with a resection rate of 49% in patients classified as LAPC-1, 32% in LAPC-2, and 11% in LAPC-3 (p\0.001). Resected patients with improvement of the LAPC score at the time of exploration had significantly longer median overall survival compared with those with no change or progression of LAPC score (60.7 vs. 29.8 months, p = 0.006). Conclusions: Selected patients with LAPC can undergo curative-intent surgery with excellent outcomes. The proposed Johns Hopkins anatomic LAPC score provides an objective system to anticipate the probability of eventual surgical resection after induction therapy.Tabled 1FP08-3VariableLAPC patients(n=415)LAPC-1 patients(n=67)LAPC-2 patients (n=60)LAPC-3 patients (n=288)p-valueMale, n (%)195 (47)33 (49)26 (43)135 (47)0.62Race, n (%)Caucasian348 (84)62 (93)52 (87)236 (82)0.36Age (years)Mean (SD)65.2 (10.1)63.2 (9.7)65.6 (9.9)65.4 (10.7)0.51Involvement of major vessels, n (%) Abutment (≤180°)0.008PV/SMV70 (17)19 (28)18 (30)33 (11)Celiac artery35 ( 8 )9 (13)12 (20)14 ( 5 )Superior mesenteric artery68 (16)17 (25)19 (32)32 (11)Common hepatic artery21 ( 5 )5 ( 7 )5 ( 8 )11 ( 4 )Encasement (>180°)<0.001 PV/SMV282 (68)26 (39)54 (90)202 (70) Celiac artery164 (40)11 (16)31 (52)122 (42) Superior mesenteric artery196 (47)3 ( 4 )15 (25)178 (62) Common hepatic artery213 (51)20 (30)39 (65)154 (53)Induction chemotherapy, n (%)0.30 FOLFIRINOX-based189 (50)34 (51)25 (42)130 (45) FOLFIRINOX/Gemcitabine combo72 (19)11 (16)15 (25)46 (16) Gemcitabine-based117 (31)20 (30)12 (20)85 (30)Time administered, months0.69 Median (IQR)4 (3-6)5 (4-6)5 (4-6)4 (3-6)Induction radiotherapy, n (%)222 (54)51 (76)41 (68)130 (45)0.001Modality, n (%)0.03 SBRT160 (72)40 (60)34 (57)86 (30) IMRT/standard radiation therapy62 (28)11 (16)7 (12)44 (15)Time from neoadjuvant therapy to operation, weeks0.74 Median (IQR)6 (5-8)6 (5-7)6 (5-8)6 (5-8)Surgical exploration, n (%)<0.001 Yes116 (28)42 (63)24 (40)50 (17) No299 (72)25 (37)36 (60)238 (83)Operation outcome, n (%)<0.001 Resected84 (20)33 (49)19 (32)32 (11) Not resected331 (80)34 (51)41 (68)256 (89) Open table in a new tab