Outcomes of neoadjuvant chemotherapy in resectable, borderline resectable and locally advanced pancreatic cancer

Background. The problem of neoadjuvant treatment of locally advanced (LA), borderline resectable (BR) and resectable pancreatic cancer (RPC) is being actively discussed at the present time, although the indications for its use have not been fully determined. In our work, we want to discuss the outcomes of using neoadjuvant chemotherapy (NACT) in these patients.

Materials and methods. From 2016 to 2020, 85 patients with pancreatic cancer were observed in the clinic (37 patients with LA cancer of the pancreas; 15 with BR cancer of the pancreas and 33 with RPC). Of these, men – 33 (38.8%), women – 52 (61.2%). The average age was 64 (31–83) years. All groups had GEMOX (41.2%) and FOLFIRINOX (58.8%) regimens. Increased CA 19-9 above normal had, in the LA group – 21 (56.6%); in the BR group – 9 (60%); and in the resectable group 26 (78.8%). From 3 to 6 courses of NACT were carried out, followed by computer tomography control and decision-making on treatment tactics.

Results. In the LA group, the GEMOX (n=15) and FOLFIRINOX (n=22) modes were used. When evaluating the results after 1 follow-up examination after 2.5 months. found: 2 patients died; progression – 14 patients (37.8%); remained inoperable – 16 patients (43.2%), of whom 9 received radiation therapy. Removal of the primary tumor was performed in 5 patients (13.9%). The average OS in this group was 15 months. Fifteen patients with BR pancreatic tumors were observed. NACT was carried out with the same regimens – GEMOX (n=7) and FOLFIRINOX (n=8) – for 2.5 months. When evaluating the results after 1 follow-up examination after 2.5 months was found: 1 (7.7%) patient died; progression was noted in 6 (40%) patients; in 1 (7.7%) patient, surgical treatment was not performed due to pronounced concomitant diseases. Surgical treatment was performed in 7 (46.7%) patients. 33 patients were prescribed NACT for RPC. The main criteria for prescribing NACT for formally resectable pancreatic cancer were a high CA 19-9 level (>100 IU/ml) [n=26 (75%)] and a large primary tumor [n=7 (25%)]. All patients received the same regimens for 3.3 months. up to 1 control. When evaluating the results, the following results were obtained: 1 (3%) patient died; 3 (9.3%) patients were not operated on due to refusal from surgical treatment; 7 patients (21.9%) were not operated on due to progression. Surgical treatment was performed in 22 (66.7%) patients; Whipple procedure in 17 patients, distal resection in 3 patients, total pancreatoduodenectomy in 2 patients. At the same time, complete morphological responce was noted in 2 (9%) patients, R0 resection in 19 (86%) patients, R1 – in 1 patient (4.5%). The median survival rate of the operated patients was 20.2 months (CI 13.2–27.2 months). Most patients (65.9%) had a high level of CA 19-9, which was studied in dynamics and used as a marker of the biological activity of the tumor.

Conclusion. Thus, we can claim that NACT is absolutely indicated for all patients with LA and BR pancreatic cancer, and its role in the selection of the most favorable in relation to the prognosis of patients is indisputable. Perioperative chemotherapy in patients with RPC is still controversial; however, having in mind the results in groups with LA and BR pancreatic cancer and the literature data, we dare to assume that for this issue it is a matter of time and future randomized trials. And here an important role can be played by the CA 19-9 level, which characterizes a biologically aggressive tumor, but again, prospective randomized studies are required to study this issue in more detail.