C. Barnes1, M. Aldakkak1, K. Christians1, C. Clarke1, P. Ritch2, B. George2, M. Aburajab5, M. Griffin4, B. Erickson3, W. Hall3, D. Evans1, S. Tsai1 1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Department Of Hematology And Oncology,Milwaukee, WI, USA 3Medical College Of Wisconsin,Department Of Radiation Oncology,Milwaukee, WI, USA 4Medical College Of Wisconsin,Department Of Radiology,Milwaukee, WI, USA 5Medical College Of Wisconsin,Department Of Gastroenterology And Hepatology,Milwaukee, WI, USA
Introduction: Among patients with pancreatic cancer (PC) who are treated with a surgery-first approach, median survival is approximately two years and over 20% have local disease as the first site of recurrence; likely related to the high rates of node positive (~60%) and margin positive (~40%) disease. In contrast, neoadjuvant therapy and surgery have been associated with median survival durations of greater than three years and decreased rates of lymph node and margin positivity. The improved survival implies a greater level of systemic disease control; the importance of local disease control is controversial largely due to a lack of available data.
Methods: Consecutive patients with localized PC who received neoadjuvant therapy and surgery underwent post-treatment radiographic surveillance at 3-4 month intervals for the first 2 years and at 6 month intervals thereafter. The first site(s) of failure was classified as local recurrence (LR) for peripancreatic or perivascular recurrences, regional recurrence (RR) for peritoneal or abdominal wall recurrences, and distant recurrence (DR) for all other recurrence sites.
Results: Neoadjuvant therapy and surgery was completed in 231 consecutive patients; 115 (50%) with resectable and 116 (50%) with borderline resectable PC. Neoadjuvant therapy consisted of chemoradiation (n=75, 32%), chemotherapy alone (37, 16%), or both (119, 52%). Of the 231 patients, 137 (60%) had node negative disease and 207 (90%) had margin negative resections. Postoperative adjuvant therapy was completed in 138 (60%) of the 231 patients, including 27 (12%) patients who received adjuvant chemoradiation. At a median follow-up of 24.3 months, disease recurrence was present in 128 (55%) of the 231 patients (the first site(s) of recurrence are summarized in Figure 1). Of the 231 patients, 221 (96%) received radiation and 10 (4%) did not. Isolated LR occurred in 3 (30%) of the 10 patients with no radiation and 16 (7%) of the 221 patients who received radiation (p=0.04). Median overall survival (OS) was 43 months; not reached, 31.5, 19.4, and 24.8 months for patients with no recurrence, isolated LR, any RR without DR, and any DR, respectively.
Conclusion: Patients who successfully complete all intended neoadjuvant therapy and surgery have a median OS greater than three years, and a greater than 50% reduction in isolated LR. Despite the increased length of survival observed with neoadjuvant therapy, LR rates have not increased. As survival duration increases, neoadjuvant chemoradiation may be an important treatment component in minimizing isolated LR, which may be a preventable cause of patient death.
