Multimodality therapy offers a chance for cure in patients with pancreatic adenocarcinoma deemed unresectable at first operative exploration

Abstract

Background: Patients identified at surgical exploration with unresectable pancreatic ductal adenocarcinoma receive palliative, noncurative therapy. We hypothesized that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients deemed unresectable at previous exploration the possibility for curative salvage pancreatectomy.

Study design: Review of a prospectively maintained pancreatic ductal adenocarcinoma database identified all patients (1990 to 2010) evaluated after being deemed unresectable at first exploration elsewhere. Referring hospitals were categorized per National Cancer Data Base criteria as academic, community, or international. Patients were restaged using objective imaging (CT) criteria and classified based on anatomic resectability. Clinicopathologic factors and cancer-related outcomes were assessed.

Results: We evaluated 88 patients who underwent previously unsuccessful resection attempts at academic (n = 50), community (n = 25), and international (n = 13) centers. Radiographic restaging confirmed that 7 (8%) patient tumors were locally advanced and unresectable, but 81 (92%) were resectable (n = 61) or borderline resectable (n = 20). Using a surgery first (9%) or preoperative chemoradiation (91%) approach, successful reoperative pancreatectomy was performed in 66 (81%) patients, with 94% receiving R0 resections. Vascular resection/reconstruction was required in 30 (46%) patients and 50 (76%) required complex revision of previously created biliary/gastrointestinal bypass. The major complication rate was 20% and 3 (4.5%) patients died perioperatively. Median overall survival was 29.6 months for successfully resected patients vs 10.6 and 5.1 months (p < 0.0001) for those patients with locally advanced unresectable disease at initial referral or in whom metastatic disease developed before resection, respectively.

Conclusions: In this very selected cohort of high-risk patients, the majority had anatomically resectable tumors on restaging. Accurate radiographic restaging, a multimodality treatment strategy, and advanced surgical techniques can provide an opportunity for cure in a substantial proportion of select patients who were deemed unresectable at exploration.

Figure 1

(A) Proportion of study patients who underwent previous resection attempts categorized according to NCDB criteria. (B) Number of referred patients per year by type of referring institution showing no trend over time.

Figure 2

Radiographic anatomical re-staging classification with subsequent therapy disposition and outcomes for entire study cohort.

Figure 3

Kaplan-Meier overall survival curves for all patients by eventual outcome. Red line, unresectable at referral (n=7), median overall survival 10.5 mo; yellow line, metastasis before resection (n=15), median overall survival 5.1 mo; and greend line, successfully resected (n=66), median overall survival 29.6 mo; p<0.0001.