HPB
Jennifer Yonkus, MD
General Surgery Resident
Mayo Clinic, United States
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Resection of presumed oligometastatic pancreatic ductal adenocarcinoma (PDAC) has historically been ineffective, however modern systemic therapies now confer longer survival. Thus, re-evaluating surgical resection of PDAC in carefully selected patients with limited peritoneal metastasis (PM) warrants consideration.
Methods:
From 2018-2021, PDAC patients with positive cytology or limited PM at staging laparoscopy without extra-peritoneal metastases and durable response to neoadjuvant chemotherapy (NAT) were prospectively enrolled in a phase I trial. Treatment included laparoscopic HIPEC with cisplatin and mitomycin C for 1-3 cycles followed by CR+HIPEC; including definitive management of the primary tumor by either formal resection, irreversible electroporation (IRE), or intraoperative radiation therapy (IORT). A matched cohort of patients (n=11) who all received chemotherapy and had limited PM or positive cytology identified on staging laparoscopy from 2015-2018 was identified for comparison.
Results: 19 patients underwent either IRE (11/19), formal resection (7/19), or IORT (1/19) with CR+HIPEC. Median # of NAT cycles was 14 (IQR 12-17) and all had radiographic and/or biochemical response. Median PCI was 2 (IQR 0-3). A complete cytoreduction was achieved in all. Median LOS was 7 days (IQR 6-8) and 42% experienced grade > 3 complication, including one 30-day and one additional 90-day post-op mortality. At median follow-up of 12 mos (IQR 4-17), 7 patients had disease progression with median recurrence-free survival of 20 mos. The peritoneum was the most common site of recurrence (5/7). Median OS in the CR+HIPEC cohort was 42 months from date of diagnosis which compared favorably to the matched cohort who received only systemic chemotherapy (42 vs 21 mos, p< 0.01, Figure).
Conclusions:
This pilot study demonstrates that CR+HIPEC for selective patients with PM from PDAC is safe and feasible however further studies are needed. A phase II trial (NCT04858009) is enrolling at our institution to assess the efficacy of this multimodal approach in select patients.