Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA.
Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA.
J Gastrointest Surg. 2018 Feb;22(2):235-241. doi: 10.1007/s11605-017-3556-1. Epub 2017 Sep 11.
Modern-era systemic therapy for locally advanced pancreatic adenocarcinoma (LAPC) offers improved survival relative to historical regimens but not necessarily improved radiographic downstaging to allow more patients to undergo resection. The aim of this study was to evaluate the survival, progression, and pathologic outcomes after resection of LAPC that did not regress from > 180 degrees arterial encasement after neoadjuvant therapy.
Sixty-one LAPC patients were brought to the operating room after neoadjuvant therapy for NCCN-defined unresectable pancreatic cancer between 2012 and 2017. Pts were explored with intent of pancreatectomy and irreversible electroporation for margin extension; 5 (8%) had metastatic lesions on exploratory laparoscopy and were excluded from analyses. Imaging was re-examined to confirm LAPC prior to surgery. Data were analyzed from a prospective pancreatic cancer database.
Patients had arterial involvement of the celiac axis (37.5%) and/or superior mesenteric artery (42.9%) and/or an extended length of the common hepatic (n = 44.6%) artery. Twenty-nine males and 27 females, median 65 years of age, received neoadjuvant gemcitabine-based (58.9%) or FOLFIRINOX (35.7%) chemotherapy and stereotactic body (42.9%) or intensity-modulated (51.8%) radiation therapy. Median months from initiation of neoadjuvant therapy to surgery was 7.5. Sixty-one percent underwent Whipple, 21% distal, and 18% modified Appleby procedures; 57% patients underwent venous reconstruction. Ninety-day mortality was 2%. An R0 margin was achieved in 80%, and 53% were N0. Median overall and progression-free survival was 18.5 (95%CI 12.27-32.33) and 8.5 months (95%CI 6.0-15.0), respectively. One- and 3-year survival from surgery was 68.5% (95%CI 53.0-79.7) and 39.0% (95%CI 23.7-53.8), respectively.
With modern-era neoadjuvant therapy, R0 resections can be achieved in a majority of non-metastatic patients with locally advanced, unresectable disease based on cross-sectional imaging.
与历史方案相比，局部晚期胰腺腺癌（LAPC）的现代系统治疗可提高生存率，但不一定能降低影像学降期，以使更多患者能够接受手术切除。本研究旨在评估新辅助治疗后未能从> 180°动脉包绕退缩的 LAPC 患者手术后的生存、进展和病理结局。
2012 年至 2017 年间，61 例 NCCN 定义为不可切除的胰腺癌患者在新辅助治疗后被带到手术室接受治疗。患者接受探查性剖腹手术和不可逆电穿孔以扩大切缘；5 例（8%）在腹腔镜探查时发现转移性病变，被排除在分析之外。在手术前重新检查影像学以确认 LAPC。数据来自前瞻性胰腺癌数据库。
患者有腹腔动脉（37.5%）和/或肠系膜上动脉（42.9%）和/或肝总动脉（n=44.6%）的广泛受累。29 名男性和 27 名女性，中位年龄 65 岁，接受新辅助吉西他滨为基础（58.9%）或 FOLFIRINOX（35.7%）化疗和立体定向体部（42.9%）或强度调制（51.8%）放射治疗。从新辅助治疗开始到手术的中位时间为 7.5 个月。61%行胰十二指肠切除术，21%行胰体尾切除术，18%行改良 Appleby 手术；57%的患者行静脉重建。90 天死亡率为 2%。80%达到 R0 切缘，53%为 N0。中位总生存期和无进展生存期分别为 18.5 个月（95%CI 12.27-32.33）和 8.5 个月（95%CI 6.0-15.0）。手术 1 年和 3 年的生存率分别为 68.5%（95%CI 53.0-79.7）和 39.0%（95%CI 23.7-53.8）。
在现代新辅助治疗时代，根据横断面成像，大多数非转移性局部晚期、不可切除的患者可实现 R0 切除。
