ASO Author Reflections: Tumor Biology and Safe Surgery Remain Major Determinants of Survival After Resection of Pancreat
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Tumor Biology and Safe Surgery Remain Major Determinants of Survival After Resection of Pancreatic Adenocarcinoma Timothy E. Newhook, MD, and Ching-Wei D. Tzeng, MD Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
PAST Pancreatic ductal adenocarcinoma remains a complex disease in which incremental gains in survival have been difficult to achieve, even within the patient population with putatively localized disease. Because of this struggle for any improvements in survival outcomes, scrutiny of all phases of care, including the perioperative period, has led to increased focus on reducing major complications and minimizing the surgical stress response. Along these lines, a prior report found that a single dose of intravenous dexamethasone used for prophylaxis against postoperative nausea and vomiting reduced complications and nearly doubled the survival rate of resected patients.1 As a component of many chemotherapy regimens and an immunomodulator, it is possible that dexamethasone may have short-term and long-term positive effects on PDAC surgery. However, we hypothesized that a single dose of dexamethasone would not supersede the importance of underlying biologic factors and major complications. PRESENT Multimodality therapy (MMT), consisting of modern doublet and triplet chemotherapy regimens, along with safe surgical resection, offers the best survival rates for patients with pancreatic ductal adenocarcinoma (PDAC). In our evaluation of 373 resected PDAC patients at our institution
Ó Society of Surgical Oncology 2020 First Received: 19 August 2020 Accepted: 21 August 2020 C.-W. D. Tzeng, MD e-mail: [email protected]
(2011–2018), intraoperative dexamethasone was not associated with differences in short-term outcomes, such as postoperative major complications (PMCs).2 Furthermore, dexamethasone was not associated with any improvement in recurrence-free or overall survival. After adjusting for clinical factors, only final pathologic node positivity, perineural invasion, PMCs, and multimodality therapy (MMT) were independently associated with OS. Intraoperative dexamethasone, while clinically useful for mitigating PONV, should not be counted upon to have any impact on immediate surgical or long-term oncologic outcomes. FUTURE Biologic tumor characteristics, such as nodal metastases and perineural invasion, are the inherent and seemingly immutable factors associated with oncologic outcomes for PDAC patients. However, neoadjuvant therapy can (and does) downstage clinically node-positive patients to potentially launch them into a better echelon of survival, similar to that of clinically node-negative patients.3 The importance of receiving MMT and avoiding PMCs cannot be overstated for surgical PDAC management, because the aforementioned underlying tumor biology and the conduct of the operation are the main drivers of oncologic outcomes despite contemporary enhanced recovery protocols.4 Even in the United States, the 90-day
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