Borderline resectable pancreatic cancer: the importance of this emerging stage of disease

Abstract

Background: Patients with borderline resectable pancreatic adenocarcinoma (PA) include those with localized disease who have tumor or patient characteristics that preclude immediate surgery. There is no optimal treatment schema for this distinct stage of disease, so the role of surgery is undefined.

Study design: We defined patients with borderline resectable PA as fitting into one of three distinct groups. Group A comprised patients with tumor abutment of the visceral arteries or short-segment occlusion of the Superior Mesenteric Vein. In group B, patients had findings suggestive but not diagnostic of metastasis. Group C patients were of marginal performance status. Patients were treated initially with chemotherapy, chemoradiation, or both; those of sufficient performance status who completed preoperative therapy without disease progression were considered for surgery.

Results: Between October 1999 and August 2006, 160 (7%) of 2,454 patients with PA were classified as borderline resectable. Of these, 125 (78%) completed preoperative therapy and restaging, and 66 (41%) underwent pancreatectomy. Vascular resection was required in 18 (27%) of 66 patients, and 62 (94%) underwent a margin-negative pancreatectomy. A partial pathologic response to induction therapy (< 50% viable tumor) was seen in 37 (56%) of 66 patients. Median survival was 40 months for the 66 patients who completed all therapy and 13 months for the 94 patients who did not undergo pancreatectomy (p < 0.001).

Conclusions: This is the first large report of borderline resectable PA and includes objective definitions for this stage of disease. Our neoadjuvant approach allowed for identification of the marked subset of patients that was most likely to benefit from surgery, as evidenced by the favorable median survival in this group.

FIGURE 1

Treatment approach for patients with borderline resectable pancreatic cancer. All patients were initially evaluated with a comprehensive staging evaluation and an assessment of performance status (see text). Patients staged as borderline resectable were treated with induction chemotherapy and/or chemoradiation. After preoperative therapy was complete, restaging was performed to select those patients most likely to benefit from surgery. CTX, chemotherapy; CXRT, chemoradiation.

FIGURE 2

Treatment of 160 patients with borderline resectable pancreatic cancer. All patients were received induction therapy; 125 (78%) patients completed therapy and returned for preoperative restaging. Surgery was recommended in 82 patients, of whom 79 underwent operation; 66 (41% of 160 total patients) were resected. Reasons for failure to receive all therapy included the development of disease progression and/or an irreversible decline in performance status.

FIGURE 3

Kaplan-Meier curves illustrating the actuarial survival of patients with resected and unresected pancreatic cancer for each borderline subtype (A-C), and for all 160 patients (D). In each group, patients who completed all therapy including surgery had a significant survival advantage compared to patients who did not undergo surgical resection.

FIGURE 3

Kaplan-Meier curves illustrating the actuarial survival of patients with resected and unresected pancreatic cancer for each borderline subtype (A-C), and for all 160 patients (D). In each group, patients who completed all therapy including surgery had a significant survival advantage compared to patients who did not undergo surgical resection.

FIGURE 3

Kaplan-Meier curves illustrating the actuarial survival of patients with resected and unresected pancreatic cancer for each borderline subtype (A-C), and for all 160 patients (D). In each group, patients who completed all therapy including surgery had a significant survival advantage compared to patients who did not undergo surgical resection.

FIGURE 3

Kaplan-Meier curves illustrating the actuarial survival of patients with resected and unresected pancreatic cancer for each borderline subtype (A-C), and for all 160 patients (D). In each group, patients who completed all therapy including surgery had a significant survival advantage compared to patients who did not undergo surgical resection.