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Adjuvant Chemoradiotherapy in Resected Pancreatic Ductal Adenocarcinoma: Where Does the Benefit Lie? A Nomogram for Risk Stratification and Patient Selection

  • Original Article
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Journal of Gastrointestinal Surgery

Abstract

Introduction

The impact of adjuvant sequential chemoradiotherapy (CRT) on survival in resected pancreatic ductal adenocarcinoma (PDAC) remains unclear and warrants further investigation.

Methods

NCDB patients with R0/R1 resected PDAC who received adjuvant chemotherapy without CRT or followed by CRT per RTOG-0848 protocol were included. Cox regression for 5-year overall survival (OS) was performed and used to construct a pathologic nomogram in patients who did not receive CRT. A risk score was calculated and patients were divided into low-risk and high-risk groups. Patients from each risk stratum were matched for the receipt of CRT to assess the added benefit of CRT on survival. The Kaplan–Meier analysis was performed to compare OS.

Results

A total of 7146 patients were selected, 1308 (18.3%) received CRT per RTOG-0848. Cox regression concluded grade, T stage, N stage, node yield < 12, R1, and LVI as significant predictors of 5-year OS which were used to construct the risk score. Matched analysis in low-risk patients (score 0–79) showed no difference in OS between CRT vs. no CRT (47.6 ± 5.7 vs. 45.1 ± 3.9 months; p = 0.847). OS benefit was 3% at 1 year, − 4% at 2 years, and 4% at 5 years. In high-risk patients (score 80–100), median OS was higher in CRT vs. no CRT (24.8 ± 0.7 vs. 21.7 ± 0.8 months; p = 0.043). Absolute OS benefit was 13% at 1 year, 5% at 2 years, and − 1% at 5 years.

Conclusion

CRT has a short-lived impact on OS in resected PDAC that is only evident in high-risk patients. In this subset, survival benefit peaks at 1 year and subsides at 3 to 5 years following PDAC resection.

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Authors and Affiliations

  1. Department of Surgical Oncology, H. Lee Moffitt Cancer Center, 12902 USF Magnolia Drive, CSB 8165, Tampa, FL, 33612, USA

    Samer A. Naffouje & Arvind Sabesan

  2. Medical Oncology, GI Oncology Program, H. Lee Moffitt Cancer Center, Tampa, FL, USA

    Dae-Won Kim & Estrella Carballido

  3. Radiation Oncology, GI Oncology Program, H. Lee Moffitt Cancer Center, Tampa, FL, USA

    Jessica Frakes & Sarah Hoffe

  4. Surgical Oncology, GI Oncology Program, H. Lee Moffitt Cancer Center, Tampa, FL, USA

    Pamela Hodul, Jason W. Denbo, Mokenge Malafa & Jason Fleming

Authors
  1. Samer A. Naffouje
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  2. Arvind Sabesan
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  3. Dae-Won Kim
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  4. Estrella Carballido
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  5. Jessica Frakes
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  6. Pamela Hodul
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  7. Jason W. Denbo
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  8. Mokenge Malafa
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  9. Jason Fleming
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  10. Sarah Hoffe
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Contributions

Study conception and design: SN, AS, JF, SH.

Acquisition of data: SN, AS

Analysis and interpretation of data: SN, AS, JF, SH

Drafting of the manuscript: SN, AS, JF, SH

Critical revision: SN, AS, DWK, EC, JF, PH, JD, MM, JF, SH

All authors have read and approved the manuscript.

This manuscript is not under consideration elsewhere. Data acquisition in this work was completed via an approved access to the NCDB Participant User File (PUF). The authors are not authorized to release data to third parties per their agreement with the American College of Surgeons.

Corresponding author

Correspondence to Samer A. Naffouje.

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The authors declare no competing interests.

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Synopsis

The role of adjuvant radiation in resected pancreatic ductal adenocarcinoma (PDAC) remains unclear. In this work, we use the NCDB to emulate the settings of arm IV in the RTOG 0848 to study the influence of the added adjuvant radiation in patients who received surgical resection of PDAC and completed adjuvant chemotherapy. Our analysis concludes a “high-risk pathologic profile” for patients who demonstrate a survival benefit for the first 2 years after resection, suggesting an improved local control. However, this benefit subsides by 5 years likely due to the more common systemic recurrence.

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Naffouje, S.A., Sabesan, A., Kim, DW. et al. Adjuvant Chemoradiotherapy in Resected Pancreatic Ductal Adenocarcinoma: Where Does the Benefit Lie? A Nomogram for Risk Stratification and Patient Selection. J Gastrointest Surg 26, 376–386 (2022). https://doi.org/10.1007/s11605-021-05130-x

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  • DOI: https://doi.org/10.1007/s11605-021-05130-x

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