CT evaluation after neoadjuvant FOLFIRINOX chemotherapy for borderline and locally advanced pancreatic adenocarcinoma
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To assess anatomic changes on computed tomography (CT) after neoadjuvant FOLFIRINOX (5-fluorouracil/leucovorin/irinotecan/oxaliplatin) chemotherapy for secondary resected borderline resectable (BR) and locally advanced (LA) pancreatic adenocarcinoma and their accuracy to predict resectability and pathological response.
Thirty-six patients with secondary resected BR/LA pancreatic adenocarcinoma after neoadjuvant FOLFIRINOX chemotherapy (± chemoradiotherapy) were retrospectively included. Two radiologists reviewed baseline and pre-surgical CTs in consensus. NCCN (National Comprehensive Cancer Network) classification, largest axis, product of the three axes (P3A), and arterial/venous involvement were studied and compared to pathological response and resection status and to disease-free survival (DFS).
Thirty-one patients had R0 resection, including only six exhibiting a downstaging according to the NCCN classification. After treatment, the largest axis and P3A decreased (P < 0.0001). The pre-surgical largest axis and P3A were smaller in case of R0 resection (P = 0.019/P = 0.021). The largest axis/P3A variations were higher in case of complete pathological response (P = 0.011/P = 0.016). A decrease of the arterial/venous involvement was not able to predict R0 or ypT0N0 (P > 0.05). Progression of the vascular involvement was seen in two (5 %) patients and led to a shorter DFS.
In BR/LA pancreatic adenocarcinoma after the neoadjuvant FOLFIRINOX regimen (± chemoradiotherapy), significant tumour size decreases were observed on CT. However, CT staging was not predictive of resectability and pathological response.
• Significant tumour size decreases were observed on CT after FOLFIRINOX (± chemoradiotherapy).
• CT is not able to predict R0 resection accurately after FOLFIRINOX (± chemoradiotherapy).
• CT is not able to predict complete response accurately after FOLFIRINOX (± chemoradiotherapy).
• Even with a stable NCCN classification, BR/LA pancreatic adenocarcinoma could have R0 resection.
KeywordsPancreatic adenocarcinoma Computed tomography Neoadjuvant treatment FOLFIRINOX Staging
National Comprehensive Cancer Network
product of the three axes
response evaluation criteria in solid tumours
region of interest
superior mesenteric artery
superior mesenteric vein
The scientific guarantor of this publication is Jean-Baptiste Bachet. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained. Written informed consent was waived by the Institutional Review Board.
All patients of the current study were included in a larger clinical study, which reports the postoperative and oncological outcomes of secondary pancreatic resection after neoadjuvant FOLFIRINOX in patients with initially BR or LA pancreatic adenocarcinoma (Pietrasz et al, Ann Surg Oncol 2015). This study focussed on the outcomes and did not overlap with the current study, as no imaging data were evaluated after the treatment in Pietrasz et al.
Ten patients of the current study were also included in a radiological study, assessing CT evaluation after neoadjuvant chemotherapy and chemoradiotherapy, whatever the chemotherapy regimen (Cassinotto et al, Radiology 2014). This study included only locally advanced pancreatic head adenocarcinoma, treated by neoadjuvant chemotherapy and chemoradiotherapy. Unlike in our study, the chemotherapy regimen was either GEMOX or FOLFORINOX. Even if there is an overlap between this study and the current study, the aim of the current study was to focus on the accuracy of CT to assess response after FOLFIRINOX and to predict complete resection after this specific chemotherapy regimen. Moreover, the scoring system used to assess the vascular involvement was different in the current study and we also assessed the downstaging according to the NCCN guidelines.
Methodology: retrospective, observational, multicentre study.
- 9.NCCN. National Comprehensive Cancer Network. NCCN practice guidelines for pancreatic cancer, version 2. Available at http://www.nccn.org/professionals/physician_glslrecently_updated.asp. 2014.
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