Anatomic Criteria Determine Resectability in Locally Advanced Pancreatic Cancer

BACKGROUND: The introduction of multi-agent chemotherapy and radiation therapy has facilitated potential resection with curative intent in selected LAPC patients with excellent outcomes. Nevertheless, there remains a remarkable lack of consensus on the management of LAPC. We sought to describe the outcomes of patients with LAPC and objectively define the multidisciplinary selection process for operative exploration based on anatomical factors. METHODS: Consecutive patients with LAPC were evaluated in the multidisciplinary clinic of a high-volume institution for pancreatic surgery between 2013 and 2018. Prospective stratification (LAPC-1, LAPC-2, and LAPC-3), based on the involvement of regional anatomical structures, was performed at the time of presentation prior to initiation of treatment. Resection rates and patient outcomes were evaluated and correlated with initial anatomic stratification system. RESULTS: Overall, 415 patients with LAPC were included in the study, of whom 84 (20%) were successfully resected with a median overall survival of 35.3 months. The likelihood of operative exploration was associated with the pre-treatment anatomic LAPC score with a resection rate of 49% in patients classified as LAPC-1, 32% in LAPC-2, and 11% in LAPC-3 (p<0.001). Resected patients with improvement of the LAPC score at the time of exploration had significantly longer median overall survival as compared to those with no change or progression of LAPC score (60.7 vs 29.8 months, p=0.006). CONCLUSIONS: Selected patients with LAPC can undergo curative-intent surgery with excellent outcomes. The proposed Johns Hopkins anatomic LAPC score provides an objective system to anticipate the probability of eventual surgical resection after induction therapy.