Success rate of salvage neoadjuvant chemotherapy for unexpectedly identified locally advanced pancreatic ductal adenocarcinoma during surgical exploration.

BACKGROUND

For unexpected locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) found during surgical exploration, surgeons can risk an incomplete resection or abort surgery to administer salvage neoadjuvant chemotherapy (sNACT). We aim to evaluate the outcomes of sNACT.

METHODS

Upfront PDAC resections between 2015-2022 were identified, focusing on surgery aborted due to local inoperability. Demographics, treatment, and survival rates were compared with patients who had upfront vascular or R1-direct resection.

RESULTS

Among 382 resections, 33 surgeries were aborted due to local inoperability (8.7 %). Only 20/33 of the patients with intraoperative decision for sNACT received it, mostly FOLFIRINOX (17/33). Patients who did not undergo sNACT were older [73 (64-80) vs 64 (56-71), p = 0.027] and had a higher ASA-score [ASA III-IV: 8 (61.5) vs 5 (38.5), p = 0.005]. Thirteen patients underwent re-exploration after sNACT and ten had a resection, with no major complications. Median overall survival was 14.9 months (95 % CI 9.5-20.3) for the salvage group and 20.1 months for the upfront vascular/R1-direct group (95 % CI 12.8-27.4) (p = 0.107).

CONCLUSION

Salvage NACT shows 30 % resection rate, low operative morbidity, and non-inferior survival outcomes. Frail patients are less likely to undergo sNACT and may benefit from upfront surgery if technically feasible.