Outcomes of surgery for borderline and locally advanced pancreatic cancer following neoadjuvant chemotherapy

Abstract Introduction Neoadjuvant chemotherapy (NAT) is standard treatment for borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC), aiming to shrink tumors, eliminate micrometastases, and assess tumor biology. However, not all patients proceed to resection due to disease progression or contraindications. This study evaluates predictors for resectability and surgical outcomes in patients receiving NAT. Method This retrospective cohort study included patients with BRPC or LAPC treated with NAT at Umeå University Hospital between January 2020 and December 2023. Clinical data and odds of undergoing resection were analyzed using logistic regression. Postoperative complications were assessed using Clavien-Dindo. Survival was estimated using Kaplan-Meier curves. Result Among 60 patients (26 BRPC, 34 LAPC), 36 (60%) underwent surgical exploration based on performance status, stable disease or tumor regression on imaging, and stable or decreasing CA19-9. Of these, 28 (77.8%) had tumor resection. Eight patients (22.2%) had disseminated disease found intraoperatively. In multivariable analysis, increasing age was associated with reduced odds of resection (OR: 0.88, 95% CI: 0.80–0.96, p=0.005). CA19-9 levels and BRPC/LAPC status were not significantly associated with resectability. Median overall survival for resected patients was 25.7 months. Postoperative complications (Clavien-Dindo ≥3b) occurred in 4 (14.3%) patients at 30 days and 5 (17.8%) patients at 90 days. Procedure-specific complications included delayed gastric emptying (14.2%) and post-pancreatectomy hemorrhage (10.7%). Discussion Increasing age decrease the likelihood of completing NAT and undergoing resection for BRPC and LAPC. Other commonly considered markers like CA19-9 and anatomical classification were not predictive. These findings emphasize the need for improved criteria in selecting surgical candidates.