IMPACT OF A NON-THERAPEUTIC LAPAROTOMY IN PATIENTS WITH LOCALLY ADVANCED PANCREATIC CANCER UNDERGOING SURGICAL EXPLORATION TREATED WITH INDUCTION (M)FOLFIRINOX; A TAPS CONSORTIUM STUDY

Importance: Guidelines recommend surgical exploration in selected patients with locally advanced pancreatic cancer (LAPC) following induction chemotherapy. However, surgical exploration, has potential drawbacks related to surgical risks and treatment breaks, which apply in particular to patients undergoing exploration without resection (i.e. non-therapeutic laparotomy). Data regarding the impact of non-therapeutic laparotomy for LAPC treated with (m)FOLFIRINOX induction chemotherapy could guide aggresiveness of surgeons for this patient population.
Objective: To assess the incidence and oncologic impact of a non-therapeutic laparotomy for LAPC treated with (m)FOLFIRINOX induction chemotherapy.
Design: Retrospective cohort study
Setting: International multicenter study including patients from 5 referral centers in the USA and The Netherlands (2012-2019).
Participants: Patients diagnosed with pathology-proven LAPC treated with ≥1 cycle (m)FOLFIRINOX (± radiotherapy). Patients with metastatic disease on radiologic (re)staging or clinical deterioration during induction therapy were excluded. Patients undergoing non-therapeutic laparotomy (group A) were compared to those not explored (group B). Patients undergoing resection were assigned to group C.
Main outcomes and measures: 90-day mortality, palliative systemic treatment, and median OS from date of pathology-proven diagnosis.
Results: Overall, 663 patients with LAPC were included, of whom 78 (11.8%) subsequently received a second-line induction chemotherapy after (m)FOLFIRINOX and 413 (66.8%) received radiotherapy. In total, 67 patients (10.1%) were included in group A, 425 patients (64.1%) in group B, and 171 patients (25.8%) in group C. Resection was aborted in 28.2% (n=67/238) of all surgical explorations, commonly due to occult metastases (n=30/238, 12.6%). The 90-day mortality in group A was 3.0% (n=2/67). The proportion of patients receiving palliative therapy did not differ between groups A and B (65.9% vs. 73.1%; P=0.307). Median OS for groups A and B were 20.4 (95%CI; 15.9-27.3) and 20.2 (95%CI; 19.1-22.7) months respectively (P=0.752). Median OS in group C was 36.1 (95%CI; 30.5-41.2) months. Corresponding 3-year survival rates for all groups were 25.0%, 21.4% and 51.1%, respectively. Compared to unexplored patients, non-therapeutic laparotomy was not associated with reduced OS (HR=0.88 [95%CI 0.61-1.27]) in Cox regression analysis.
Conclusion and relevance: Even in experienced hands, about ¼ of surgically explored LAPC patient will remain unresectable. However, non-therapeutic laparotomy does not appear to substantially reduce short- and long-term outcomes compared to similar patients who are not explored.