Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, TX.
Surgery. 2019 Jun;165(6):1144-1150. doi: 10.1016/j.surg.2018.12.009. Epub 2019 Feb 10.
Nodal metastases portend a poor prognosis in patients with localized pancreatic cancer. Neoadjuvant therapy is associated with pathologic nodal downstaging in up to 38% of patients. However, the optimal type of neoadjuvant therapy for achieving nodal downstaging is unclear.
We conducted a retrospective cohort study of patients with nonmetastatic, clinically node-positive pancreatic cancer treated with neoadjuvant therapy and surgery identified in the National Cancer Database (2006-2014). Patients were stratified based on the neoadjuvant therapy regimens they received: multiagent chemotherapy; single-agent chemotherapy; multiagent chemotherapy with radiation; and single-agent chemotherapy with radiation. Associations between nodal downstaging and the type of neoadjuvant therapy received and overall risk of death were evaluated using multivariable regression analyses.
Among the 603 pancreatic ductal adenocarcinoma patients treated with neoadjuvant therapy, 400 received multiagent chemotherapy (202 with radiation) and 203 received single agent chemotherapy (151 with radiation). Relative to multiagent chemotherapy, single-agent chemotherapy was associated with a lower likelihood of nodal downstaging (relative risk ratio 0.38 [95% CI 0.17-0.85]). Use of radiation was associated with a significantly greater likelihood of nodal response (single-agent chemotherapy with radiation: relative risk ratio 1.77 [1.36-2.30]; multiagent chemotherapy with radiation: relative risk ratio 1.91 [1.49-2.45]; radiation use overall (versus no radiation): relative risk ratio 2.12 [1.68-2.68]). Compared with patients who remained pathologically node positive after neoadjuvant therapy, node negative status was associated with a significantly lower risk of death (hazard ratio 0.61 [0.49-0.76]) regardless of whether radiation was used (hazard ratio 0.63 [0.48-0.82]) or not (hazard ratio 0.45 [0.29-0.72]).
Nodal downstaging is associated with a survival benefit in patients with node-positive pancreatic ductal adenocarcinoma and is most likely to be achieved with neoadjuvant therapy that includes radiation. Single-agent chemotherapy neoadjuvant therapy was least likely to result in nodal downstaging.
局部胰腺癌患者出现淋巴结转移预示着预后不良。新辅助治疗与多达 38%的患者病理淋巴结降级相关。然而，实现淋巴结降级的最佳新辅助治疗类型仍不清楚。
我们对国家癌症数据库（2006-2014 年）中接受新辅助治疗和手术的非转移性、临床淋巴结阳性胰腺癌患者进行了回顾性队列研究。根据患者接受的新辅助治疗方案对患者进行分层：多药化疗；单药化疗；联合放化疗；单药放化疗。使用多变量回归分析评估淋巴结降级与新辅助治疗类型的相关性以及总体死亡风险。
在接受新辅助治疗的 603 例胰腺导管腺癌患者中，400 例接受多药化疗（202 例联合放疗），203 例接受单药化疗（151 例联合放疗）。与多药化疗相比，单药化疗淋巴结降级的可能性较低（相对风险比 0.38[95%CI0.17-0.85]）。放疗的应用与淋巴结反应的可能性显著增加相关（单药化疗联合放疗：相对风险比 1.77[1.36-2.30]；多药化疗联合放疗：相对风险比 1.91[1.49-2.45]；总体放疗使用（与无放疗相比）：相对风险比 2.12[1.68-2.68]）。与新辅助治疗后病理仍为淋巴结阳性的患者相比，淋巴结阴性状态与死亡风险显著降低相关（风险比 0.61[0.49-0.76]），无论是否使用放疗（风险比 0.63[0.48-0.82]）或未使用放疗（风险比 0.45[0.29-0.72]）。
淋巴结降级与淋巴结阳性胰腺导管腺癌患者的生存获益相关，最有可能通过包括放疗的新辅助治疗来实现。单药化疗新辅助治疗最不可能导致淋巴结降级。
