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Locally Advanced Pancreatic Cancer: Induction Chemo with Whipple Procedure + Vascular Targets

In a certain way, the initial treatment considerations for local and advanced pancreatic cancer (ductal adenocarcinoma of the pancreas) are not as complex as those of locally advanced pancreatic cancer. Local cancer is typically treated with surgical resection – some version of the Whipple Procedure. And the treatment of advanced pancreatic cancer is generally some form of chemotherapy regimen. The “standard” for non-operable locally advanced pancreatic cancer has been chemoradiation. And an active area of inquiry has been the best treatment option for borderline resectable locally advanced pancreatic cancer, or perhaps unresectable locally advanced pancreatic cancer as based on vascular encasement or abutment by the tumor.

Now comes a study by Allendorf and his surgical colleagues from Columbia University in New York City that examines outcomes for over five hundred patients who received the pancreaticoduodenectomy (Whipple) surgery for locally advanced pancreatic cancer at Columbia from the years 1992 to 2011. The authors’ review of patient records treated at their institution initially found 643 patients with locally advanced disease who had appeared to fit surgical criteria. At surgery, only 506 of these patients were found by the operating surgeon to merit surgery. Published in the May 2014 edition of the World Journal of Surgery, the authors looked at survival duration in terms of neoadjuvant status as well as whether vascular resection was done.

The authors found that although neoadjuvant therapy appeared associated with an increase in operative mortality (7% vs. 3%), that more neoadjuvant pancreatic cancer patients underwent vascular resection, and that neoadjuvant therapy status significantly increased overall survival (as compared to no receipt of neoadjuvant treatment) at a p < 0.5 confidence level of 27.3months versus 19.7 months.

It tentatively appears that certain patients with apparently unresectable locally advanced pancreatic cancer – as determined by traditional criteria – may gain a potentially improved survival advantage if they respond to neoadjuvant therapy such that they then become candidates for pancreatic surgery, including vascular resection.

This is an interesting and fine study that on one hand further complicates the treatment landscape for locally advanced pancreatic cancer, but offers potential improved results for many.

 

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Dale O’Brien, MD