ASO Author Reflections: The Sequential Radiographic Effects of Preoperative Chemotherapy and (Chemo)Radiation on Tumor A
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: The Sequential Radiographic Effects of Preoperative Chemotherapy and (Chemo)Radiation on Tumor Anatomy in Patients with Localized Pancreatic Cancer Giampaolo Perri, MD1, and Matthew H. G. Katz, MD2 Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy; 2Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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PAST Radiographic downstaging of localized pancreatic adenocarcinoma has historically been an uncommon event following preoperative therapy. We previously identified only one patient among 122 who had a borderline resectable tumor that was downstaged to resectable after preoperative gemcitabine-based chemotherapy with or without chemoradiation.1 Many have assumed that higher response rates associated with FOLFIRINOX and gemcitabine plus nab-paclitaxel relative to gemcitabine alone in metastatic patients indicates higher rates of local downstaging after preoperative therapy. Thus, these two systemic regimens, with or without subsequent (chemo)radiation, continue to be administered to ‘‘shrink’’ the size and/or anatomic extent of borderline or locally advanced cancers to facilitate pancreatectomy. PRESENT In the current study, using data generated by two highvolume pancreatic cancer treatment centers, we found that a RECIST 1.1 partial response or radiographic downstaging were present in less than one third of patients who underwent laparoscopy or laparotomy following treatment with preoperative FOLFIRINOX or gemcitabine/nab-paclitaxel with or without subsequent (chemo)radiation.2 The magnitude of tumor volume loss was greater and the
Ó Society of Surgical Oncology 2020 First Received: 16 April 2020 M. H. G. Katz, MD e-mail: [email protected]
incidence of downstaging was higher (28% and 24% compared with 17% and 6%, respectively) following induction chemotherapy than after subsequent (chemo)radiation. We and others have shown that radiographic downstaging is not uniformly necessary to allow resection of well-selected pancreatic tumors.1,3 Together, these results emphasize that FOLFIRINOX or gemcitabine/nabpaclitaxel and (chemo)radiation therapy should not be used with the primary intention of ‘‘shrinking’’ a locally advanced cancer away from the mesenteric vessels prior to surgical resection. FUTURE So, if preoperative therapy does not typically ‘‘shrink’’ cancers to ‘‘resectability,’’ what is its purpose, and how can we measure its effect? All localized cancers—even small, minimally invasive, technically resectable ones—are associated with micrometastases and the possibility of margin-positive resection due to occult retroperitoneal invasion by cancer cells. Preoperative therapy is thus most appropriately delivered to treat systemic cancer and to select patients with any anatomic stage of disease who have tumors with a ‘‘locally dominant phenotype,’’ for which surgery is most likely to be meaningful. Increasing evidence suggests that radiomic and serologic biomarkers can serve as r
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