Georgios Gemenetzis1,2, Alex B Blair1, Minako Nagai1,3, William R Burns1, Christopher L Wolfgang4, Jin He5, Vincent P Groot1,6, Ding Ding1, Ammar A Javed1, Richard A Burkhart1, Elliot K Fishman7, Ralph H Hruban8, Matthew J Weiss1,9, John L Cameron1, Amol Narang10, Daniel Laheru11, Kelly Lafaro1, Joseph M Herman12, Lei Zheng11. 1. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 2. Department of Surgery, Royal Infirmary Edinburgh, Edinburgh, Scotland, UK. 3. Department of Surgery, Nara Medical University, Nara, Japan. 4. Department of Surgery, New York University, New York, NY, USA. 5. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. jhe11@jhmi.edu. 6. Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. 7. Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 8. Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 9. Department of Surgery, Northwell Health, Manhasset, NY, USA. 10. Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 11. Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 12. Department of Radiation Oncology, Northwell Health, Manhasset, NY, USA.
Abstract
BACKGROUND: The introduction of multi-agent chemotherapy and radiation therapy has facilitated potential resection with curative intent in selected locally advanced pancreatic cancer (LAPC) patients with excellent outcomes. Nevertheless, there remains a remarkable lack of consensus on the management of LAPC. We sought to describe the outcomes of patients with LAPC and objectively define the multidisciplinary selection process for operative exploration based on anatomical factors. METHODS: Consecutive patients with LAPC were evaluated for pancreatic surgery in the multidisciplinary clinic of a high-volume institution, between 2013 and 2018. Prospective stratification (LAPC-1, LAPC-2, and LAPC-3), based on the involvement of regional anatomical structures, was performed at the time of presentation prior to the initiation of treatment. Resection rates and patient outcomes were evaluated and correlated with the initial anatomic stratification system. RESULTS: Overall, 415 patients with LAPC were included in the study, of whom 84 (20%) were successfully resected, with a median overall survival of 35.3 months. The likelihood of operative exploration was associated with the pretreatment anatomic LAPC score, with a resection rate of 49% in patients classified as LAPC-1, 32% in LAPC-2, and 11% in LAPC-3 (p < 0.001). Resected patients with improvement of the LAPC score at the time of exploration had significantly longer median overall survival compared with those with no change or progression of LAPC score (60.7 vs. 29.8 months, p = 0.006). CONCLUSIONS: Selected patients with LAPC can undergo curative-intent surgery with excellent outcomes. The proposed Johns Hopkins anatomic LAPC score provides an objective system to anticipate the probability of eventual surgical resection after induction therapy.
BACKGROUND: The introduction of multi-agent chemotherapy and radiation therapy has facilitated potential resection with curative intent in selected locally advanced pancreatic cancer (LAPC) patients with excellent outcomes. Nevertheless, there remains a remarkable lack of consensus on the management of LAPC. We sought to describe the outcomes of patients with LAPC and objectively define the multidisciplinary selection process for operative exploration based on anatomical factors. METHODS: Consecutive patients with LAPC were evaluated for pancreatic surgery in the multidisciplinary clinic of a high-volume institution, between 2013 and 2018. Prospective stratification (LAPC-1, LAPC-2, and LAPC-3), based on the involvement of regional anatomical structures, was performed at the time of presentation prior to the initiation of treatment. Resection rates and patient outcomes were evaluated and correlated with the initial anatomic stratification system. RESULTS: Overall, 415 patients with LAPC were included in the study, of whom 84 (20%) were successfully resected, with a median overall survival of 35.3 months. The likelihood of operative exploration was associated with the pretreatment anatomic LAPC score, with a resection rate of 49% in patients classified as LAPC-1, 32% in LAPC-2, and 11% in LAPC-3 (p < 0.001). Resected patients with improvement of the LAPC score at the time of exploration had significantly longer median overall survival compared with those with no change or progression of LAPC score (60.7 vs. 29.8 months, p = 0.006). CONCLUSIONS: Selected patients with LAPC can undergo curative-intent surgery with excellent outcomes. The proposed Johns Hopkins anatomic LAPC score provides an objective system to anticipate the probability of eventual surgical resection after induction therapy.
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