Postoperative complications and overall survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

Predictors of long-term survival after pancreaticoduodenectomy for peri-ampullary adenocarcinoma: A retrospective study of 5-year survivors

BACKGROUND

Pancreaticoduodenectomy (PD) is the standard curative treatment for periampullary tumors. The aim of this study is to report the incidence and predictors of long-term survival (≥ 5 years) after PD.

METHODS

This study included patients who underwent PD for pathologically proven periampullary adenocarcinomas. Patients were divided into 2 groups: group (I) patients who survived less than 5 years and group (II) patients who survived ≥ 5 years.

RESULTS

There were 47 (20.6%) long-term survivors (≥ 5 years) among 228 patients underwent PD for periampullary adenocarcinoma. Patients with ampullary adenocarcinoma represented 31 (66.0%) of the long-term survivors. Primary analysis showed that favourable factors for long-term survival include age < 60 years old, serum CEA < 5 ng/mL, serum CA 19-9 < 37 U/mL, non-cirrhotic liver, tumor size < 2 cm, site of primary tumor, postoperative pancreatic fistula, R0 resection, postoperative chemotherapy, and no recurrence. Multivariate analysis demonstrated that CA 19-9 < 37 U/mL [OR (95% CI) = 1.712 (1.248-2.348), P = 0.001], smaller tumor size [OR (95% CI )= 1.335 (1.032-1.726), P = 0.028] and Ro resection [OR (95% CI) = 3.098 (2.095-4.582), P < 0.001] were independent factors for survival ≥ 5 years. The prognosis was best for ampullary adenocarcinoma, for which the median survival was 54 months and 5-year survival rate was 39.0%, and the poorest was pancreatic head adenocarcinoma, for which the median survival was 27 months and 5-year survival rate was 7%.

CONCLUSIONS

The majority of long-term survivors after PD for periampullary adenocarcinoma are patients with ampullary tumor. CA 19-9 < 37 U/mL, smaller tumor size, and R0 resection were found to be independent factors for long-term survival ≥ 5 years.

Can physician gestalt predict survival in patients with resectable pancreatic adenocarcinoma?

PURPOSE

Clinician gestalt may hold unexplored information that can be capitalized upon to improve existing nomograms. The study objective was to evaluate physician ability to predict 2-year overall survival (OS) in resected pancreatic ductal adenocarcinoma (PDAC) patients based on pre-operative clinical characteristics and routine CT imaging.

METHODS

Ten surgeons and two radiologists were provided with a clinical vignette (including age, gender, presenting symptoms, and pre-operative CA19-9 when available) and pre-operative CT scan for 20 resected PDAC patients and asked to predict the probability of each patient reaching 2-year OS. Receiver operating characteristic curves were used to assess agreement and to compare performance with an established institutional nomogram.

RESULTS

Ten surgeons and 2 radiologists participated in this study. The area under the curve (AUC) for all physicians was 0.707 (95% CI 0.642-0.772). Attending physicians with > 5 years experience performed better than physicians with < 5 years of clinical experience since completion of post-graduate training (AUC = 0.710, 95% CI [0.536-0.884] compared to AUC = 0.662, 95% CI [0.398-0.927]). Radiologists performed better than surgeons (AUC = 0.875, 95% CI [0.765-0.985] compared to AUC = 0.656, 95% CI [0.580-0.732]). All but one physician outperformed the clinical nomogram (AUC = 0.604).

CONCLUSIONS

This pilot study demonstrated significant promise in the quantification of physician gestalt. While PDAC remains a difficult disease to prognosticate, physicians, particularly those with more clinical experience and radiologic expertise, are able to perform with higher accuracy than existing nomograms in predicting 2-year survival.

Clinical Management: Resectable Disease

Despite the identification of more active systemic therapy combinations for pancreatic cancer, cures remain elusive and feasible only in patients with localized, operable disease. When examining outcome data from phase III adjuvant trials conducted during the past decade, the survival for patients with localized disease has improved, likely owing to a combination of factors including more active adjuvant therapy and improved surgical and perioperative care. Perhaps the greatest recent change in the care of patients with localized pancreatic cancer has been the extension of surgery to tumors previously thought to be inoperable because of involvement of major blood vessels. These so-called "borderline resectable pancreatic cancers" have now been objectively defined, and their management is being studied in randomized trials. This has been made feasible by the availability of more active systemic therapy combinations that are increasingly being used in the neoadjuvant setting. Given the increasing activity of systemic regimens, the challenges in delivering such therapy in the postoperative setting, and the numerous novel agents in late stages of clinical development, it is reasonable to hypothesize that the neoadjuvant setting may eventually become the standard of care for patients with resectable disease.

Prognostic impact of postoperative complication after pancreatoduodenectomy for pancreatic adenocarcinoma stratified by the resectability status

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate the prognostic impact of postoperative complications after pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) stratified by resectability status.

METHODS

Medical records of 226 patients with pancreatic head carcinoma who underwent PD, including 115 with resectable (R) and 111 with borderline resectable/unresectable (BR/UR) PDAC, were reviewed retrospectively. Major complications were defined as grade III or IV based on the Clavien-Dindo classification system. The prognostic impact of major complications on overall survival (OS) was analyzed using univariate and multivariate analyses with stratification by resectability status.

RESULTS

A multivariate analysis in the BR/UR group identified R1 resection (P = 0.03), T 3/4 stage (P = 0.03), and incidence of major complications (P = 0.03) as independent risk factors for poor survival, whereas major complications did not affect survival in the R group. Initiation of adjuvant gemcitabine plus S-1 chemotherapy occurred significantly less frequently for patients with major complications than for those without major complications in the BR/UR group (P = 0.02).

CONCLUSION

A negative prognostic impact of postoperative major complications after PD was observed in patients with BR/UR PDAC, whereas the prognostic impact was unclear in patients with R PDAC.

[Investigations on in-hospital mortality in pancreatic surgery : Results of a multicenter observational study]

BACKGROUND

The rate of hospital mortality (in-hospital mortality) after complex pancreatic resections cannot be used as a decision-making criterion with no further analysis and specification. Such analysis has to provide a risk-adjusted benchmarking including a continuous evaluation taking into account the frequency of a surgical procedure and its competent perioperative management.

MATERIAL AND METHODS

As part of the Prospective Evaluation study Elective Pancreatic surgery (PEEP), overall 2003 patients were enrolled over a 3-year time period from 01 January 2006 to 12 December 2008, who underwent elective pancreatic surgery in 27 surgical departments. Included in the study were only hospitals which perform pancreatic resections. In addition to the analysis of the current situation of the operative treatment of pancreatic diseases, the complex aspects of the in-hospital mortality as a main outcome parameter were investigated.

RESULTS

Out of all enrolled patients (n = 2003), 75 patients (3.7%) died during the hospital stay. In the group of 1045 patients with partial pancreaticoduodenectomy (PD), 43 patients did not survive the hospital stay (4.1%). Similarly, such low in-hospital mortality rates were observed after total pancreatoduodenectomy (3.8%) and after left-sided resection of the pancreas (1.9%). With respect to a univariate risk stratification, advanced age and an American Society of Anaesthesiologists (ASA) score of 3 and 4 had a significant impact on in-hospital mortality. Multivariate regression analysis within the PD group revealed an increased need for blood transfusions and a delay in oral feeding as factors closely associated with specific complications with a significant impact on in-hospital mortality. Significant differences in the in-hospital mortality rates were found when comparing hospital volume groups, such as 10-20 vs. >20 cases/year for the 831 Kausch-Whipple procedures for adenocarcinoma and chronic pancreatitis.

DISCUSSION

An adequate in-hospital mortality rate in the continuous benchmarking represents an acceptable quality level of structural and therapeutic predictions in pancreatic resections. The participation of surgical departments with complex oncosurgical interventions in clinical multicenter observational studies as a contribution to research on surgical care appears reasonable and recommendable since the results of such studies can provide a contribution to decision-making processes in daily surgical practice.

Prevention of pancreatic fistula using polyethylene glycolic acid mesh reinforcement around pancreatojejunostomy: the propensity score-matched analysis

BACKGROUND

Several small-scale studies have shown that wrapping polyethylene glycolic acid (PGA) mesh around the anastomotic site reinforced pancreaticojejunostomy following pancreatoduodenectomy (PD) with favorable outcomes. This study investigated the efficacy of PGA mesh for reducing postoperative pancreatic fistula (POPF) and evaluated other risk factors for POPF.

METHODS

This study enrolled 464 consecutive patients who underwent PD performed by one surgeon between 2006 and 2015, including a PGA group of 281 patients (60.6%) and a control group of 183 patients (39.4%). All pancreatico-enteric anastomoses were performed using double-layered, duct-to-mucosa, end-to-side pancreaticojejunostomy.

RESULTS

Mean patient age was 63.1 years. The rates of overall (27.0% vs. 37.2%, P = 0.024) and clinically relevant (Grades B, C; 13.9% vs. 24.0%, P = 0.006) POPF were significantly lower in the PGA than in the control group. Following propensity score matching, the rates of clinically relevant POPF (12.6% vs. 22.4%, P = 0.024) and complications (40.2% vs. 63.8%, P < 0.001) remained significantly lower in the PGA group. Multivariate analysis showed that non-pancreatic disease, greater blood loss, higher body mass index, and non-application of PGA mesh were significantly associated with the development of clinically relevant POPF.

CONCLUSIONS

PGA mesh reinforcement of pancreaticojejunostomy may prevent POPF as well as reducing overall abdominal complications after PD.

Wireless Monitoring Program of Patient-Centered Outcomes and Recovery Before and After Major Abdominal Cancer Surgery

Importance

A combined subjective and objective wireless monitoring program of patient-centered outcomes can be carried out in patients before and after major abdominal cancer surgery.

Objective

To conduct a proof-of-concept pilot study of a wireless, patient-centered outcomes monitoring program before and after major abdominal cancer surgery.

Design, Setting, and Participants

In this proof-of-concept pilot study, patients wore wristband pedometers and completed online patient-reported outcome surveys (symptoms and quality of life) 3 to 7 days before surgery, during hospitalization, and up to 2 weeks after discharge. Reminders via email were generated for all moderate to severe scores for symptoms and quality of life. Surgery-related data were collected via electronic medical records, and complications were calculated using the Clavien-Dindo classification. The study was carried out in the inpatient and outpatient surgical oncology unit of one National Cancer Institute-designated comprehensive cancer center. Eligible patients were scheduled to undergo curative resection for hepatobiliary and gastrointestinal cancers, were English speaking, and were 18 years or older. Twenty participants were enrolled over 4 months. The study dates were April 1, 2015, to July 31, 2016.

Main Outcomes and Measures

Outcomes included adherence to wearing the pedometer, adherence to completing the surveys (MD Anderson Symptom Inventory and EuroQol 5-dimensional descriptive system), and satisfaction with the monitoring program.

Results

This study included a final sample of 20 patients (median age, 55.5 years [range, 22-74 years]; 15 [75%] female) with evaluable data. Pedometer adherence (88% [17 of 20] before surgery vs 83% [16 of 20] after discharge) was higher than survey adherence (65% to 75% [13 of 20 and 15 of 20] completed). The median number of daily steps at day 7 was 1689 (19% of daily steps at baseline), which correlated with the Comprehensive Complication Index, for which the median was 15 of 100 (r = -0.64, P < .05). Postdischarge overall symptom severity (2.3 of 10) and symptom interference with activities (3.5 of 10) were mild. Pain (4.4 of 10), fatigue (4.7 of 10), and appetite loss (4.0 of 10) were moderate after surgery. Quality-of-life scores were lowest at discharge (66.6 of 100) but improved at week 2 (73.9 of 100). While patient-reported outcomes returned to baseline at 2 weeks, the number of daily steps was only one-third of preoperative baseline.

Conclusions and Relevance

Wireless monitoring of combined subjective and objective patient-centered outcomes can be carried out in the surgical oncology setting. Preoperative and postoperative patient-centered outcomes have the potential of identifying high-risk populations who may need additional interventions to support postoperative functional and symptom recovery.

Systematic review and meta-analysis of robotic versus open pancreaticoduodenectomy

BACKGROUND

Although robotic pancreaticoduodenectomy (RPD) has been successfully performed since 2003, its advantages over open pancreaticoduodenectomy (OPD) are still uncertain. The aim of this systematic review and meta-analysis was to compare the clinical outcomes of RPD to those of OPD.

METHODS

A systematic literature review was performed to identify RPD versus OPD comparative studies published between January 2003 and January 2016. Intraoperative outcomes, post-operative outcomes and oncologic safety were evaluated. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with a 95% confidence interval (95% CI) were calculated using fixed-effect or random-effect models.

RESULTS

Nine non-randomized observational clinical studies involving 680 patients met the inclusion criteria and involved 245 RPDs and 435 OPDs. The overall complication rate was significantly lower in RPD (OR 0.65, 95% CI 0.47-0.91, P = 0.012), as well as the margin positivity rate (OR 0.40, 95% CI 0.20-0.77, P = 0.006), the wound infection rate (OR 0.18, 95% CI 0.06-0.53, P = 0.002) and the length of hospital stay (WMD = -6.00, 95% CI -9.80 to -2.21, P = 0.002). There was no significant difference in the following: the number of lymph nodes harvested; the operation time; the reoperation rate; the incidence of delayed gastric emptying, bile leakage, pancreatic fistula and clinically significant pancreatic fistula; and mortality. The mean conversion rate was 7.3% (range 0-14%).

CONCLUSIONS

According to the results of this meta-analysis, RPD is as safe and efficient as OPD and is even favourable in terms of margin-negative resection, overall complication and wound infection rates and length of hospital stay. Given that there have not yet been any high-quality randomized controlled trials (RCTs), the evidence is still limited. Additional prospective, multi-centre RCTs are needed to further define the role of the robotic technique in PD.

The role of preoperative C-reactive protein and procalcitonin as predictors of post-pancreaticoduodenectomy infective complications: A prospective observational study

INTRODUCTION

The common causes of morbidity after pancreaticoduodenectomy (PD) are infective complications. Till date, no specific preoperative markers have been identified to determine the probability of developing infective complications. We have studied the factors predicting the occurrence of the infective complication/s in the present study.

METHODS

The present prospective observational study included 133 consecutive patients who underwent PD from January 2011 to June 2016 at a specialized hepatopancreaticobiliary surgical oncology unit. The surgeries were done using a standardized technique. Postoperative complications were segregated into two categories-(a) infective (e.g. cholangitis) and (b) non-infective (e.g. delayed gastric emptying). Increased age, preoperative serum albumin levels, preoperative biliary stenting, pre-stenting serum bilirubin levels, duration of common bile duct stenting, preoperative C-reactive protein [CRP], and procalcitonin [PCT] were evaluated.

RESULTS

Overall morbidity rate was 48.8%. Morbidity associated with infective complications was 21.8%. Increased age, preoperative serum albumin levels, and pre-stenting serum bilirubin levels did not increase the rate of the infective complications. The association between preoperative PCT and preoperative CRP with the infective complications was significant with a p-value of <0.01 (6.75E-07) and <0.01 (4.80E-10), respectively. In the multivariate analysis, only the elevated preoperative procalcitonin was a statistically significant predictor of postoperative infective complications.

CONCLUSION

Preoperative PCT and CRP levels done 48 h before surgery are sensitive, specific, easily available, and cost-effective predictors of infective complications after PD.

C-Reactive Protein/Albumin Ratio and Prognostic Nutritional Index Are Strong Prognostic Indicators of Survival in Resected Pancreatic Ductal Adenocarcinoma

Purpose: We evaluated the clinical importance, such as the occurrence of postoperative pancreatic fistula (POPF) or prognosis, of preoperative serum markers of chronic inflammation, nutrition, and immunity, as well as that of serum tumor markers after curative resection of pancreatic ductal adenocarcinomas (PDACs). Methods: Between 2006 and 2015, 43 patients with PDACs underwent curative resection at Tottori Prefectural Central Hospital. We analyzed which preoperative indicators (i.e., C-reactive protein/albumin ratio [CAR], neutrophil/lymphocyte ratio [NLR], prognostic nutritional index [PNI], carcinoembryonic antigen [CEA], and carbohydrate antigen 19-9 [CA 19-9]) were the most relevant risk factors for occurrence of POPF and poor patient survival. Results: POPF was detected in 8/43 (18.6%) patients. One patient died of pancreatic fistula at 2 months postoperatively. Among nine candidate factors (operative procedure, operation time, tumor stage, preoperative serum amylase, preoperative CAR, NLR, PNI, CEA, and CA 19-9), we did not identify any significant risk factor for the occurrence of POPF. The 5-year overall survival (OS) rate of the 43 patients was 22.4%, and the overall median survival time was 21 months. The multivariate OS analysis demonstrated that high CAR and low PNI were strong preoperative markers of poor prognosis independently of tumor stage. Conclusions: Preoperative CAR and PNI are useful prognostic markers for patients with operable PDACs.

The Cost of Postoperative Pancreatic Fistula Versus the Cost of Pasireotide: Results from a Prospective Randomized Trial

OBJECTIVE

The objective of this study was to determine the costs of clinically significant postoperative pancreatic fistula (POPF) and to evaluate the cost-effectiveness of routine pasireotide use.

SUMMARY OF BACKGROUND DATA

We recently completed a prospective randomized trial that demonstrated an 11.7% absolute risk reduction of clinically significant POPF with use of perioperative pasireotide in patients undergoing pancreaticoduodenectomy or distal pancreatectomy [POPF: pasireotide (n = 152), 9% vs placebo (n = 148), 21%; P = 0.006].

METHODS

An institutional modeling system was utilized to obtain total direct cost estimates from the 300 patients included in the trial. This system identified direct costs of hospitalization, physician fees, laboratory tests, invasive procedures, outpatient encounters, and readmissions. Total direct costs were calculated from the index admission to 90 days after resection. Costs were converted to Medicare proportional dollars (MP$).

RESULTS

Clinically significant POPF occurred in 45 of the 300 randomized patients (15%). The mean total cost for all patients was MP$23,400 (MP$8,000 - MP$202,500). The mean cost for those who developed clinically significant POPF was MP$39,700 (MP$13,800 - MP$202,500) versus MP$20,500 (MP$8,000 - MP$62,900) for those who did not (P = 0.001). The mean cost of pasireotide within the treatment group (n = 152) was MP$3,300 (MP$300 - MP$3,800). The mean cost was lower in the pasireotide (n = 152) group than the placebo (n = 148) group; however, this did not reach statistical significance (pasireotide, MP$22,800 vs placebo, MP$23,900: P = 0.571).

CONCLUSIONS

The development of POPF nearly doubled the total cost of pancreatic resection. In this randomized trial, the routine use of pasireotide significantly reduced the occurrence of POPF without increasing the overall cost of care.

Surveillance strategy for small asymptomatic non-functional pancreatic neuroendocrine tumors - a systematic review and meta-analysis

BACKGROUND

Non-functional pancreatic neuroendocrine tumors (NF-PNET) are rare neoplasms being increasingly diagnosed. Surgical treatment or expectant management are both suggested for small NF-PNETs. The aim of this study was to evaluate the outcome of surveillance strategy for small NF-PNETs.

METHODS

A systematic search was performed up to March 2016 in MEDLINE, EMBASE and the Cochrane Library according to the PRISMA guidelines. Data was pooled using the random-effects model.

RESULTS

Nine articles including 344 patients with sporadic and 64 patients with MEN1 related NF-PNET were selected. Tumor growth was observed in 22% and 52%, development of metastases were reported on 0% and 9%, and rate of secondary surgical resection was 12% and 25% in patients with sporadic or MEN1 related NF-PNETs, respectively. All metastases (1 distant, 4 nodal) were reported by a single study in patients with MEN1. Reason for secondary surgery was tumor growth in half of patients undergoing surgery.

DISCUSSION

Expectant management of small asymptomatic, sporadic, NF-PNETs could be a reasonable option in highly selected patients. However, the level of evidence is low and longer follow-up is needed to identify patients could benefit from upfront surgery instead of expectant treatment.

Postoperative Complications and Long-Term Survival After Complex Cancer Resection

BACKGROUND

Recent attention has focused on the ability to rescue patients from postoperative complications and prevent short-term mortality. However, it is unknown whether patients rescued from complications after complex cancer resections have long-term survival outcomes similar to those of patients without complications.

METHODS

From 2005 to 2009 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the study identified elderly patients who underwent resection for cancers of the esophagus, lung, or pancreas. The association of risk-adjusted long-term survival with serious complications, minor complications, and no complications was analyzed.

RESULTS

The study included 905 patients with esophageal cancer, 12,395 patients with lung cancer, and 1966 patients with pancreatic cancer. The serious complication rates were respectively 17.4, 9.5 and 11.8 %. The patients with serious complications had lower 5-year survival rates than those with no complications even if they were rescued and survived 30 days (20 vs 43 % for esophagus, 29 vs 54 % for lung, and 10 vs 21 % for pancreas cancer). Even after patients who died within 180 days after surgery were excluded from the analysis, a decrement in risk-adjusted long-term survival was observed among the patients with serious complications after all three procedures. The association between complications and long-term survival was not explained by differences in receipt of adjuvant chemotherapy CONCLUSION: Patients who undergo complex cancer resection and experience serious complications have diminished long-term survival, even if they are "rescued" from their complications. This finding persists even when deaths within 6 months after surgery are excluded from the analysis. Metrics of surgical success should consider terms beyond 30 and even 90 days as well as the long-term consequences of surgical complications.

Effect of Pancreatic Fistula on Recurrence and Long-Term Prognosis of Periampullary Adenocarcinomas after Pancreaticoduodenectomy

Pancreatic fistula (PF) is common after pancreaticoduodenectomy (PD). Its effect on recurrence and survival is not known. Retrospective study of patients undergoing PD for periampullary adenocarcinomas (2000–2012). Standard statistical analyses were performed to determine the impact of PF on disease-free survival (DFS) and overall survival (OS). There were 634 PDs (pancreatic adenocarcinoma: 347, other periampullary adenocarcinomas: 287). Any-grade PF developed in 81/634 (13%). Perioperative mortality rate was 1.7 per cent (11/634), higher in patients with PF (10 vs 0.5%, P < 0.001). In multivariable analysis, PF significantly reduced DFS in pancreatic [hazard ratio (HR) = 1.6, 95% confidence-interval (CI): 1.1–2.6, P = 0.043] but not in other periampullary adenocarcinomas [HR = 1.3 (95% CI: 0.8–2.2), P = 0.45]. Positive lymph nodes, margins, and high-grade histology were associated with decreased DFS and OS. Adjuvant therapy was associated with improved OS in pancreatic [HR = 0.7 (95% CI: 0.5–0.9), P = 0.02] but not in other periampullary adenocarcinomas [HR = 1.14 (95% CI: 0.8–1.7), P = 0.49]. PF did not alter OS in either group. After PD, PF is associated with decreased DFS in pancreatic but not in other periampullary adenocarcinomas. This decrease DFS did not alter OS. Tumor grade, lymph nodes, and resection margin status are associated with DFS and OS.

A new technique for minimally invasive irreversible electroporation of tumors in the head and body of the pancreas

Background

Palliative irreversible electroporation of pancreatic adenocarcinomas is rapidly gaining in interest since a large proportion of these patients cannot be radically resected.

Methods

This is a description of a minimally invasive approach to irreversible electroporation of pancreatic tumors using computer-assisted navigation, laparoscopy and laparoscopic ultrasound to correctly guide electrodes into the tissue.

Results

The procedure is presented.

Conclusion

Minimally invasive irreversible electroporation of pancreatic tumors through computer-assisted navigation of needles during laparoscopy is a feasible and accurate approach.

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-016-5173-6) contains supplementary material, which is available to authorized users.

Systematic Review of Resection Rates and Clinical Outcomes After FOLFIRINOX-Based Treatment in Patients with Locally Advanced Pancreatic Cancer

Background

FOLFIRINOX prolongs survival in patients with metastatic pancreatic cancer and may also benefit patients with locally advanced pancreatic cancer (LAPC). Furthermore, it may downstage a proportion of LAPC into (borderline) resectable disease, however data are lacking. This review assessed outcomes after FOLFIRINOX-based therapy in LAPC.

Methods

The PubMed, EMBASE and Cochrane library databases were systematically searched for studies published to 31 August 2015. Primary outcome was the (R0) resection rate.

Results

Fourteen studies involving 365 patients with LAPC were included; three studies administered a modified FOLFIRINOX regimen. Of all patients, 57 % (n = 208) received radiotherapy. The pooled resection rate was 28 % (n = 103, 77 % R0), with a perioperative mortality of 3 % (n = 2), and median overall survival ranged from 8.9 to 25.0 months. Survival data after resection were scarce, with only one study reporting a median overall survival of 24.9 months in 28 patients. A complete pathologic response was found in 6 of 85 (7 %) resected specimens. Dose reductions were described in up to 65 % of patients, grade 3–4 toxicity occurred in 23 % (n = 51) of patients, and 2 % (n = 5) had to discontinue treatment. Data of patients treated solely with FOLFIRINOX, without additional radiotherapy, were available from 292 patients: resection rate was 12 % (n = 29, 70 % R0), with 15.7 months median overall survival and 19 % (n = 34) grade 3–4 toxicity.

Conclusions

Outcomes after FOLFIRINOX-based therapy in patients with LAPC seem very promising but further prospective studies are needed, especially with regard to survival after resection.