Department of HPB surgery and liver transplantation, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
Department of Gastroenterology, Division of Digestive Oncology, Ghent University Hospital, Ghent, Belgium.
BMC Surg. 2023 Sep 30;23(1):296. doi: 10.1186/s12893-023-02200-6.
The treatment of borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) has evolved with a wider application of neoadjuvant chemotherapy (NACHT). The aim of this study was to identify predictive factors for survival in BR and LA PDAC.
Clinicopathologic data of patients with BR and LA PDAC who underwent surgical exploration between January 2011 and June 2021 were retrospectively collected. Survival from the date of surgery was estimated using the Kaplan-Meier method. Simple and multiple Cox proportional hazards models were fitted to identify factors associated with survival. Surgical resection was analyzed in combination with the involvement of lymph nodes as this last was only known after a formal resection.
Ninety patients were surgically explored (BR: 45, LA: 45), of which 51 (57%) were resected (BR: 31, LA: 20). NACHT was administered to 43 patients with FOLFIRINOX being the most frequent regimen applied (33/43, 77%). Major complications (Clavien-Dindo grade III and IV) occurred in 7.8% of patients and 90-day mortality rate was 3.3%. The median overall survival since surgery was 16 months (95% CI 12-20) in the group which underwent surgical resection and 10 months (95% CI 7-13) in the group with an unresectable tumor (p=0.001). Cox proportional hazards models showed significantly lower mortality hazard for surgical resection compared to no surgical resection, even after adjusting for National Comprehensive Cancer Network (NCCN) classification and administration of NACHT [surgical resection with involved lymph nodes vs no surgical resection (cHR 0.49; 95% CI 0.29-0.82; p=0.007)]. There was no significant difference in survival between patients with BR and LA disease (cHR= 1.01; 95% CI 0.63-1.62; p=0.98).
Surgical resection is the only predictor of survival in patients with BR and LA PDAC, regardless of their initial classification as BR or LA. Our results suggest that surgery should not be denied to patients with LA PDAC a priori. Prospective studies including patients from the moment of diagnosis are required to identify biologic and molecular markers which may allow a better selection of patients who will benefit from surgery.
随着新辅助化疗（NACHT）的广泛应用，边界可切除（BR）和局部晚期（LA）胰腺导管腺癌（PDAC）的治疗方法已经发生了变化。本研究的目的是确定 BR 和 LA PDAC 患者生存的预测因素。
回顾性收集 2011 年 1 月至 2021 年 6 月间接受手术探查的 BR 和 LA PDAC 患者的临床病理数据。从手术日期开始估计生存情况，采用 Kaplan-Meier 法。拟合简单和多 Cox 比例风险模型，以确定与生存相关的因素。手术切除与淋巴结受累相结合进行分析，因为只有在正式切除后才能知道淋巴结受累情况。
90 例患者接受了手术探查（BR：45 例，LA：45 例），其中 51 例（57%）接受了手术切除（BR：31 例，LA：20 例）。43 例患者接受了 NACHT 治疗，FOLFIRINOX 是最常用的方案（33/43，77%）。7.8%的患者发生主要并发症（Clavien-Dindo 分级 III 和 IV 级），90 天死亡率为 3.3%。在接受手术切除的患者中，中位总生存时间为 16 个月（95%CI 12-20），在肿瘤不可切除的患者中为 10 个月（95%CI 7-13）（p=0.001）。即使在校正国家综合癌症网络（NCCN）分类和 NACHT 治疗后，Cox 比例风险模型显示手术切除的死亡率显著降低[有淋巴结受累的手术切除与无手术切除（cHR 0.49；95%CI 0.29-0.82；p=0.007）]。BR 和 LA 疾病患者的生存无显著差异（cHR=1.01；95%CI 0.63-1.62；p=0.98）。
手术切除是 BR 和 LA PDAC 患者生存的唯一预测因素，与初始 BR 或 LA 分类无关。我们的结果表明，不应该预先拒绝 LA PDAC 患者手术。需要前瞻性研究，包括从诊断时起的患者，以确定可能允许更好选择将从手术中受益的患者的生物学和分子标志物。
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