Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
HPB (Oxford). 2019 Sep;21(9):1203-1210. doi: 10.1016/j.hpb.2019.01.011. Epub 2019 Feb 22.
Neoadjuvant therapy (NT) remains controversial in early-stage pancreatic ductal adenocarcinoma (PDAC), defined as clinical (c)Stage I-II. Our aim was to analyze rates of pathologic upstaging/downstaging for resectable PDAC treated with surgery-first (SF) vs. NT.
Utilizing the National Cancer Data Base (NCDB), patients with cStage I-II PDAC who underwent pancreatoduodenectomy in 2006-2013 were pathologically staged using the AJCC 8th edition and compared by treatment sequencing.
Among 13,871 patients, 15.3% received NT. Despite higher pre-treatment T-stage (cT2: 71.9% vs. 56.3%, p < 0.001), NT patients had lower rates of pathologic nodal metastases (46.2% vs. 69.2% in SF, p < 0.001), suggesting higher rates of pathologic downstaging. In cStage II, 33.0% were upstaged to stage III after SF, vs. only 14.0% after NT. In cStage I, 65.5% were upstaged following SF, vs. 46.7% after NT (all p < 0.001). Patients with NT (HR-0.77, p < 0.001) or downstaging (HR-0.80, p < 0.001) had improved overall survival (OS).
NT is associated with reduction in unexpected upstaging, reduction in nodal positivity, and improved OS, compared to SF approach in putatively early-stage PDAC. Because clinical staging underestimates the underlying disease burden in resectable PDAC, patients with cStage I-II should be considered for NT.
新辅助治疗（NT）在早期胰腺导管腺癌（PDAC）中仍存在争议，定义为临床（c）I-II 期。我们的目的是分析接受手术优先（SF）与 NT 治疗的可切除 PDAC 的病理升级/降级率。
利用国家癌症数据库（NCDB），对 2006-2013 年间接受胰十二指肠切除术的 cI-II 期 PDAC 患者进行病理分期，采用第 8 版 AJCC 分期，并按治疗顺序进行比较。
在 13871 名患者中，15.3%接受了 NT。尽管术前 T 分期更高（cT2：71.9%比 56.3%，p<0.001），但 NT 患者的病理淋巴结转移率较低（SF 组为 46.2%，比 SF 组为 69.2%，p<0.001），提示病理降级率较高。在 c 期 II 期，33.0%在 SF 后升级为 III 期，而 NT 后仅为 14.0%。在 c 期 I 期，65.5%在 SF 后升级，而 NT 后为 46.7%（均 p<0.001）。接受 NT（HR-0.77，p<0.001）或降级（HR-0.80，p<0.001）的患者总生存率（OS）改善。
与 SF 方法相比，NT 可降低意外升级率、降低淋巴结阳性率，并改善 OS，用于治疗潜在的早期 PDAC。由于临床分期低估了可切除 PDAC 患者的潜在疾病负担，因此应考虑对 cI-II 期患者进行 NT。
