Systemic Treatment Followed by Radical Resection Combined with Intestinal Autotransplantation (RRCIA) for Locally Advanced Pancreatic Cancer

Objective: The present study aimed to assess the efficacy of this approach and establish the criteria that identify LAPC patients who may achieve survival benefits from RRCIA. Summary Background Data: Surgical resection for locally advanced pancreatic cancer (LAPC) remains challenging and associated with high morbidity and mortality, especially for surgery with major arterial reconstruction. We previously showed the feasibility and safety of Radical Resection Combined with Intestinal Autotransplantation (RRCIA) after systemic treatment. Methods: A retrospectively observational and prospectively validated study with three cohorts was conducted using multiple treatments. Overall survival (OS) and progression-free survival (PFS) were compared for both analyses. Propensity-score matching (PSM) and stabilized inverse probability of treatment weighting (IPTW) were performed to adjust for potential confounders. Results: Among 208 patients with LAPC we identified 48 who underwent systemic treatment followed by RRCIA. Using Propensity-score matching (PSM) and stabilized inverse probability of treatment weighting (IPTW) analyses, we observed that patients who underwent RRCIA had better overall and progression free survival compared with patients who did not have surgery (PSM cohort: median OS: 25.8 mo vs. 14.2 mo, P =0.0031, and IPTW cohort: median OS: 23.2 mo vs. 15.4 mo, P =0.0069) and PFS (PSM cohort: median PFS: 13.3 mo vs. 7.0 mo, P =0.0246, and IPTW cohort: median OS: 13.3 mo vs. 8.8 mo, P =0.002). Further prospective analysis showed that patients who received systemic treatment followed by RRCIA were associated with improved OS and PFS compared with patients who were eligible but did not receive RRCIA (median OS: 22.6 mo vs. 18.2 mo, P =0.035; median PFS: 13.2 mo vs. 10.3 mo, P =0.0412). Moreover, stratified and multivariable analysis demonstrated that preoperative CA19-9 normalization and duration of initial treatment over 8 cycles were predictors for precise selection of patients who would benefit from RRCIA. Meanwhile, adjuvant therapy after RRCIA was a significant factor for improving survival. Conclusion: This study suggests that RRCIA appears to be effective and associated with improved outcomes for LAPC patients with favorable response to systemic treatment. LAPC patients Should have at least 8 cycles of systemic treatment and CA19-9 normalization to be considered for RRCIA.