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. 2015 Jan;261(1):12-7.
doi: 10.1097/SLA.0000000000000867.

Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer

Cristina R Ferrone  1 , Giovanni Marchegiani, Theodore S Hong, David P Ryan, Vikram Deshpande, Erin I McDonnell, Francesco Sabbatino, Daniela Dias Santos, Jill N Allen, Lawrence S Blaszkowsky, Jeffrey W Clark, Jason E Faris, Lipika Goyal, Eunice L Kwak, Janet E Murphy, David T Ting, Jennifer Y Wo, Andrew X Zhu, Andrew L Warshaw, Keith D Lillemoe, Carlos Fernández-del Castillo
Affiliations

Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer

Cristina R Ferrone et al. Ann Surg. 2015 Jan.

Abstract

Purpose: On the basis of the ACCORD trial, FOLFIRINOX is effective in metastatic pancreatic adenocarcinoma (PDAC), making it a rational choice for locally advanced PDAC (LA). Aims of this study are to evaluate the accuracy of imaging in determining the resectability of PDAC and to determine the surgical and clinicopathologic outcomes of pancreatic resections after neoadjuvant FOLFIRINOX therapy.

Patients and methods: Clinicopathologic data were retrospectively collected for surgical PDAC patients receiving neoadjuvant FOLFIRINOX or no neoadjuvant therapy between April 2011 and February 2014. Americas Hepato-Pancreato-Biliary Association/Society of Surgical Oncology/Society for Surgery of the Alimentary Tract consensus guidelines defined LA and borderline. Imaging was reviewed by a blinded senior pancreatic surgeon.

Results: Of 188 patients undergoing resection for PDAC, 40 LA/borderline received FOLFIRINOX and 87 received no neoadjuvant therapy. FOLFIRINOX resulted in a significant decrease in tumor size, yet 19 patients were still classified as LA and 9 as borderline. Despite post-FOLFIRINOX imaging suggesting continued unresectability, 92% had an R0 resection. When compared with no neoadjuvant therapy, FOLFIRINOX resulted in significantly longer operative times (393 vs 300 minutes) and blood loss (600 vs 400 mL), but significantly lower operative morbidity (36% vs 63%) and no postoperative pancreatic fistulas. Length of stay (6 vs 7 days), readmissions (20% vs 30%), and mortality were equivalent (1% vs 0%). On final pathology, the FOLFIRINOX group had a significant decrease in lymph node positivity (35% vs 79%) and perineural invasion (72% vs 95%). Median follow-up was 11 months with a significant increase in overall survival with FOLFIRINOX.

Conclusions: After neoadjuvant FOLFIRINOX imaging no longer predicts unresectability. Traditional pathologic predictors of survival are improved, and morbidity is decreased in comparison to patients with clearly resectable cancers at the time of presentation.

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Conflict of interest statement

Disclosure: The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Clinical treatment flow-chart.
Figure 2
Figure 2
A, A 54-year-old woman with LA PDAC treated with 8 cycles FOLFIRINOX and 50.4 Gy of chemoradiation. Final pathology revealed a T3N0M0 PDAC with negative margin (R0). The patient is alive and free of disease at 25 months from diagnosis. B, 56-year-old man with LA PDAC treated with 6 cycles FOLFIRINOX and CyberKnife. Both images are of postneoadjuvant treatment. Final pathology revealed no viable tumor and negative lymph nodes. The patient is free of disease at 16 months from diagnosis.
Figure 3
Figure 3
Overall survival curves for patients who were treated with neoadjuvant FOLFIRINOX versus no neoadjuvant chemotherapy.
See this image and copyright information in PMC

Comment in

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