Background: There is no standardized assessment for evaluating response although neoadjuvant chemotherapy (NAT) is widely accepted for borderline resectable or locally advanced pancreatic cancer (BRPC or LAPC). This study was aimed to evaluate NAT response using positron emission tomography (PET) with 2-deoxy-2-[fluorine-18]fluoro-D-glucose (¹⁸F-FDG-PET/CT) parameters alongside carbohydrate antigen (CA) 19-9 levels. Methods: Patients who underwent surgery after NAT for BRPC and LAPC between 2017 and 2021 were identified. The study assessed the prognostic value of PET-derived parameters after NAT, determining cutoff values using the K-adaptive partitioning method. It created four groups based on the elevation or normalization of PET parameters and CA19-9 levels, comparing survival between these groups. Results: Of 200 eligible patients, FOLFIRINOX and gemcitabine-based NAT was administered in 166 and 34 patients, respectively (mean NAT cycles, 8.3). In a multivariate analysis, metabolic tumor volume (MTV) demonstrated the most robust performance in assessing response [hazard ratio (HR) 3.11, 95% confidence interval (CI) 1.73–5.58, P<0.001] based on cutoff value of 2.4. Patients with decreased MTV had significantly better survival than those with elevated MTV among individuals with CA19-9 levels less than 37 IU/l (median survival; 35.5 vs. 20.9 months, P<0.001) and CA19-9 levels at least 37 IU/l (median survival; 34.3 vs. 17.8 months, P=0.03). In patients suspected to be Lewis antigen negative, the predictive performance of MTV was found to be limited (P=0.84). Conclusion: Elevated MTV is an influential prognostic factor for worse survival, regardless of post-NAT CA19-9 levels. These results could be helpful in identifying patients with a poor prognosis despite normalization of CA19-9 levels after NAT.

The impact of tumor location on patient survival in pancreatic ductal adenocarcinoma (PDAC) remains controversial. This study investigated the association between primary tumor location and survival rates for resectable PDAC. Additionally, we assessed if this association remains consistent across categories of the Tumor-Node-Metastasis staging system. We analyzed 2471 patients who underwent surgical resection between 2000 and 2018 at a single center. Subgroup analysis was performed according to the Tumor-Node-Metastasis staging system. Among the group, 67.9% (1677 patients) had pancreatic head cancer (PHC) and 32.1% (794 patients) had pancreatic body/tail cancer (PBTC). Patients with PHC had worse overall survival and worse disease-free survival than those with PBTC. Patients with PHC had worse survival in stage IB and stage IIB than those with PBTC. No significant difference was observed for stages IA, IIA, and III. Multivariate analysis showed that elevated CA 19-9, mGPS, a longer hospital stay, complication, accompanying vein resection, larger tumor size, worse differentiation, higher TNM stage (stage IIB, III, IV), presence of LVI, and positive resection margin were risk factors for poor survival after resection. In resectable PDAC, patients with PHC had worse overall and disease-free survival than those with PBTC. However, tumor location was not an independent prognostic factor for PDAC.

Background: The current AJCC 8th has been reported to have a poor ability to predict the prognosis in patients with resected borderline resectable pancreatic cancer and locally advanced pancreatic cancer following neoadjuvant chemotherapy. This study aimed to develop an improved prognostic model by incorporating pathology and parameters of biologic response (BR). Materials and methods: A retrospective cohort study was conducted including patients who underwent curative-intent surgery following chemotherapy. The authors developed a modified ypT staging system and incorporated the BR, involving normalization of carbohydrate antigen 19-9 and reduction in the maximum standardized uptake value simultaneously after chemotherapy. The prognostic performance of the current pathologic system, modified pathologic system, and newly developed system incorporating pathology and BR were compared. Results: In this study, 171 patients underwent surgery following chemotherapy. The modified T stage, which unified ypT2 and ypT3, demonstrated improved prognostic performance than the current staging system [area under the curve (AUC): 0.706 vs. 0.661]. Biologic unresponsiveness was an independent prognostic factor for worse survival (hazard ratio 2.31, 95% CI: 1.50–3.55, P<0.001). The modified pathology with BR system demonstrated the highest discriminative ability in predicting 5-year overall survival than the current pathologic system (AUC: 0.785 vs. 0.661, P=0.010) and modified pathologic staging system (AUC: 0.785 vs. 0.706, P=0.002). Conclusions: The prognostic model, incorporating modified ypT staging and elevated carbohydrate antigen 19-9 levels and maximum standardized uptake value simultaneously, demonstrated improved results in predicting oncologic outcomes for patients who underwent surgery following neoadjuvant chemotherapy.

Min Kyu Sung, Woohyung Lee, Sarang Hong, Yejong Park, Bong Jun Kwak, Ki Byung Song, Jae Hoon Lee, Dae Wook Hwang, Song Cheol Kim. Ann Hepatobiliary Pancreat Surg 2023;27:107-13. https://doi.org/10.14701/ahbps.22-054

Janghun Han, Woohyung Lee, Jung Bok Lee, Taemin Kim, Mirang Lee, Minkyu Sung, Kwang Pyo Hong, Seung Jae Lee, Ki Byung Song, Jae Hoon Lee, Dae Wook Hwang, Song Cheol Kim. Ann Hepatobiliary Pancreat Surg -0001;0:. https://doi.org/10.14701/ahbps.26-015