Predictors of futile surgery in upfront resectable pancreatic ductal adenocarcinoma. possible targets for neoadjuvant chemotherapy?

Background: Upfront resectable pancreatic ductal adenocarcinoma (PDAC) with evidence of disseminated disease (metastasis at surgery or recurrence within 6 months after resection) impacts outcome negatively. Neoadjuvant chemotherapy for localized PDAC has not been shown to yield the anticipated outcomes, but resectable tumours at high risk for dissemination may be suitable candidates. This study aims to identify preoperative characteristics of resectable PDAC associated with evidence of dissemination.

Methods: We conducted a retrospective single-centre study of adult patients with upfront resectable PDAC who underwent exploration or resection at the Karolinska University Hospital between 2009 and 2018. Multivariable logistic regression analysis was used to identify predictors for dissemination. Nomograms for dissemination were developed. Tumours with high and low risk for dissemination according to the nomogram were compared using Kaplan-Meier survival curves.

Results: In total 393 patients were included in the study, 105 with disseminated tumours, 186 that recurred between 6 and 24 months and 102 that had not recurred within 24 months. Independent predictors for disseminated disease for tumours in the pancreatic head and in the body/tail were CA19-9 ≥200 U/mL, and CA19-9 ≥100 U/mL as well as tumour size ≥20 mm respectively.

Conclusion: Preoperative assessment of resectable PDAC for predictors of disseminated disease may guide the selection of patients suitable for upfront resection or those that may benefit from neo-adjuvant chemotherapy.