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Multidisciplinary Management of Resectable Pancreatic Adenocarcinoma Offers Superior Long-Term Results: Presented at SSO

By Mary Beth Nierengarten

CHICAGO -- March 17, 2008 -- A multidisciplinary management approach to patients with resectable pancreatic adenocarcinoma has been shown to achieve superior 5-year survival rates over previously published series, investigators reported here March 17 during a session on gastrointestinal cancer at the Society of Surgical Oncology (SSO) 61st Annual Cancer Symposium.

Patients treated under their institution's multidisciplinary schema for pancreatic cancer (PC) achieved a 27% actual 5-year survival rate. This finding compares with 10% to 17% survival rates reported in other published series.

"We set out to critically evaluate the actual long-term outcome of patients with pancreatic adenocarcinoma who were treated by a multidisciplinary strategy of care to provide accurate and contemporary natural history data for physicians and, more importantly, for patients," said Matthew H. Katz, MD, Fellow, Surgical Oncology, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas.

The multidisciplinary schema begins with confirmation of a diagnosis of PC, followed by staging. After discussion by a multidisciplinary PC-tumour board, approximately 75% of patients receive neoadjuvant chemotherapy followed by restaging and surgical resection (for patients who have not progressed through neoadjuvant therapy). The other 25% of patients receive upfront surgery, followed by restaging, and also receive adjuvant therapy. All patients are then followed on an evidence-based schedule, and results are entered into a database.

This study examined 328 patients treated at the M. D. Anderson Cancer Center between 1990 and 2002 who underwent pancreaticoduodenectomy (n = 302), distal pancreatectomy (n = 20), or total pancreatectomy (n = 6).

Revascular reconstruction was required in 37% of patients, and 16% of patients had microscopically detected positive margins. Most patients received neoadjuvant (77%) or adjuvant (18%) therapy; 91% received chemoradiation either preoperatively or postoperatively, and 16% received chemotherapy either preoperatively or postoperatively. Surgery alone was given in only 24 (7%) of the 328 patients.

Overall, 88 of the 328 patients survived for 5 years, yielding an actual 5-year survival rate of 27%. The median survival was 24 months.

To gain a better understanding of the characteristics of the group that survived for 5 years, the authors examined a number of comparisons between these patients and the 240 patients who did not survive for 5 years.

The only operative characteristic that significantly differed between the 2 groups was the rate of reoperation, which was significantly lower in the patients who survived for 5 years compared with those who did not.

A comparison of pathologic characteristics between the 2 groups found that the 5-year survivors (n = 88) had significantly higher rates of good prognostic factors (well-differentiated tumours, negative lymph nodes, negative margins, and low lymph node ratio). Dr. Katz emphasized, however, that the presence of poor prognostic factors, such as positive nodes, did not preclude long-term survival, as was demonstrated in the finding that 36% of the 5-year survivors had positive lymph nodes.

These results contradict the belief that patients with early, well-differentiated, node-negative tumours are the only PC patients that have a chance at long-term survival, he said.

The study also examined sites of first recurrence. Overall, 207 of the 240 patients who did not survive 5 years recurred, and 50% recurred first in the liver. Of the 21 recurrences in the 5-year survivors, 62% of patients experienced first recurrence in the lung. In these patients, 14 experienced recurrence within 5 years and, of the 7 patients that recurred after 5 years, 6 developed a recurrence in the lung.

The latest recurrence in this series occurred at 6.7 years. The lack of recurrences after 7 years suggested to Dr. Katz that disease-free survival after 7 years is associated with a cure.

Overall, the authors suggest that the more favourable survival rate in this series is "likely influenced by this being a single-institution experience involving the use of objective criteria for operation, a well-established multidisciplinary treatment strategy, and an experienced clinical-management team."

[Presentation title: Long-Term Survival After Multidisciplinary Management of Resectable Pancreatic Adenocarcinoma. Abstract 14]

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