Histopathological tumour viability after neoadjuvant chemotherapy influences survival in resected pancreatic cancer: analysis of early outcome data

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The survival outcome following pancreatoduodenectomy (PD) for pancreatic cancer remains dismal despite improved surgical technique and perioperative outcomes.1 Actual 5‐year survival rates are around 15%.2 Adjuvant chemotherapy after resection is regarded standard of care following results of the European Study Group for Pancreatic Cancer (ESPAC)‐1 trial that demonstrate a 5‐year survival of 21% in patients receiving adjuvant chemotherapy versus 8% in patients who did not receive chemotherapy.4 Adding radiotherapy has been shown to result in a negative impact on overall survival from a meta‐analysis of five randomized trials.5 Circulating tumour cells have been identified in blood of patients in early stage disease and hence may be considered a systemic disease from an early stage.6
The use of neoadjuvant therapy prior to surgical resection is thought to treat occult micrometastatic disease and induce tumour shrinkage to facilitate surgery. Additionally, it allows a ‘test of tumour biology’ wherein patients whose disease progressed whilst on neoadjuvant therapy are excluded from surgery.7 Neoadjuvant therapy may also increase the chemotherapy uptake, as surgical complications often result in chemotherapy delays or omissions. In a large linkage study, Merkow et al. reported an overall adjuvant chemotherapy rates of 58% following pancreatic resection and an associated twofold reduction of rates of adjuvant chemotherapy use in the event of a serious post‐operative complication.5 In the United States, neoadjuvant chemoradiation is the preferred approach8 achieving tumour down‐staging and sterilization of the peripancreatic lymph node basin.9
The histological effect of neoadjuvant therapies and its potential to predict survival in a variety of gastrointestinal malignancies is increasingly recognized.10 The primary aims of this study were to investigate the impact of neoadjuvant chemotherapy (NAC) on post‐treatment residual tumour cells observed histopathologically and its association with survival. The secondary aims were to compare clinicopathological parameters between patients treated with NAC and a surgery‐first (SF) approach in our institutional experience.

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