Downstaging in Pancreatic Cancer: A Matched Analysis of Patients Resected Following Systemic Treatment of Initially Locally Unresectable Disease

ArticleinAnnals of Surgical Oncology 19(5):1663-9 · December 2011with7 Reads
DOI: 10.1245/s10434-011-2156-7 · Source: PubMed
Patients with locally unresectable pancreatic cancer (AJCC stage III) have a median survival of 10-14 months. The objective of this study was to evaluate outcome of initially unresectable patients who respond to multimodality therapy and undergo resection. Using a prospectively collected database, patients were identified who were initially unresectable because of vascular invasion and had sufficient response to nonoperative treatment to undergo resection. Overall survival (OS) was compared with a matched group of patients who were initially resectable. Case matching was performed using a previously validated pancreatic cancer nomogram. A total of 36 patients with initial stage III disease were identified who underwent resection after treatment with either systemic therapy or chemoradiation. Initial unresectability was determined by operative exploration (n = 15, 42%) or by cross-sectional imaging (n = 21, 58%). Resection consisted of pancreaticoduodenectomy (n = 31, 86%), distal pancreatectomy (n = 4, 11%), and total pancreatectomy (n = 1, 3%). Pathology revealed T3 lesions in 26 patients (73%), node positivity in 6 patients (16%), and a negative margin in 30 patients (83%). The median OS in this series was 25 months from resection and 30 months since treatment initiation. There was no difference in OS from time of resection between the initial stage III patients and those who presented with resectable disease (P = .35). In this study, patients who were able to undergo resection following treatment of initial stage III pancreatic cancer experienced survival similar to those who were initially resectable. Resection is indicated in this highly select group of patients.
  • [Show abstract] [Hide abstract] ABSTRACT: The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma discuss the workup and management of tumors of the exocrine pancreas. These NCCN Guidelines Insights provide a summary and explanation of major changes to the 2012 NCCN Guidelines for Pancreatic Adenocarcinoma. The panel made 3 significant updates to the guidelines: 1) more detail was added regarding multiphase CT techniques for diagnosis and staging of pancreatic cancer, and pancreas protocol MRI was added as an emerging alternative to CT; 2) the use of a fluoropyrimidine plus oxaliplatin (e.g., 5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) was added as an acceptable chemotherapy combination for patients with advanced or metastatic disease and good performance status as a category 2B recommendation; and 3) the panel developed new recommendations concerning surgical technique and pathologic analysis and reporting.
    Article · Jun 2012
  • [Show abstract] [Hide abstract] ABSTRACT: Pancreatic resection remains among the most formidable and complex of abdominal surgical operations. Nonetheless, recent observations have continued to provide incremental improvement in both our evidence for treatment regimens and the technology, resulting in better outcomes. Neoadjuvant regimens appear to have promise, at least in local control and perhaps in long-term survival. More extensive operations focusing on perineural invasion along with minimally invasive laparoscopic and robotic techniques are attracting increasing attention. The effectiveness of major vascular resection remains controversial. Concentration of patients in centers of expertise has contributed to improved outcomes. Improved management of pancreatic resections for cancer with more extensive and less-invasive surgical techniques has increased the number of patients who are candidates for effective surgical treatment.
    Article · Jul 2012
  • [Show abstract] [Hide abstract] ABSTRACT: Background We investigated the impact of downstaging on overall survival (OS) in limited disease small cell lung cancer (LD-SCLC) patients treated with first-line treatment. Patients and Methods We retrospectively reviewed 210 LD-SCLC patients who were treated with first-line treatment at Seoul National University Hospital between April 1999 and November 2012. Compared with initial TNM stage, cases that showed a lower TNM stage after treatment were defined as ‘downstaging’. The relationship between downstaging and OS was analyzed, and a subgroup analysis was performed on the responders. Results After first-line treatment, 37.1% (n=78) of patients achieved complete response, 46.2% (n=97) achieved partial response (PR), and 16.7% (n=35) experienced stable disease or progressive disease. Most patients (71.9%; n=151) showed downstaging of their diseases, and the remaining patients (28.1%; n=59) showed no change or upstaging. The median OS for patients achieving downstaging and no change/upstaging were 32.8 months and 13.1 months, respectively (P < 0.001). Of the 97 patients who achieved PR, the OS was significantly longer in patients who showed downstaging than those who did not (25.8 months vs 13.8 months, respectively; P = 0.004). In multivariate analyses, female gender, downstaging, lower initial TNM stage, and prophylactic cranial irradiation were independent good prognostic factors for OS. Conclusions Downstaging may be an independent good prognostic factor in LD-SCLC. Specifically, downstaging is expected to be useful for stratification of patients achieving PR. Further prospective studies are warranted to verify whether patients who achieved PR without downstaging can be candidates for consolidation treatments after first-line treatment.
    Article · Jan 2013
Show more