Ann Hepatobiliary Pancreat Surg.  2021 Aug;25(3):390-394. 10.14701/ahbps.2021.25.3.390.

Complete response of locally advanced left-sided pancreatic cancer after modified FOLFIRINOX chemotherapy followed by conversion surgery: A case report

• Kim SJ
• Park JY
• Hwang HS
• Kang CM

• KMID: 2519297
• DOI: http://doi.org/10.14701/ahbps.2021.25.3.390

Abstract

For years, neoadjuvant chemotherapy for locally advanced pancreatic cancer is being investigated and radical surgical resection with laparoscopic approach is getting up to speed. Pathological complete remission is known as a predictive marker for a good prognosis for various carcinomas. Although there are a few case reports about pathological complete remission, there has been no case report of pathological complete remission resulted from successful extensive resection by laparoscopic surgery after a neoadjuvant modified FOLFIRINOX chemotherapy. A 68-year-old male patient was admitted due to a palpable abdominal mass which turned out to be 16-cm-sized huge locally advanced left-sided pancreatic cancer with possible stomach, left adrenal gland, left kidney, and colon invasion. After administration of 10th modified FOLFIRINOX chemotherapy, the tumor had decreased and he underwent laparoscopic radical distal pancreatectomy with splenectomy, left adrenalectomy, wedge resection of stomach, and segmental resection of transverse colon. Although patient had a postoperative micro-abscess around the colon anastomosis site, he was successfully managed with conservative treatment and discharged on 12 days postoperatively. The final pathology reported complete tumor regression. We hereby emphasize the oncologic significance of neoadjuvant chemotherapy in huge left-sided pancreatic cancer and the potential role of laparoscopic conversion surgery.

Keyword

Locally advanced pancreatic neoplasm; Neoadjuvant chemotherapy; Complete response; Laparoscopic surgery

Figure

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  Fig. 1 (A, B) Initial abdominopelvic computed tomography showing a 16-cm sized mass in the pancreas body and tail abutting to stomach, left adrenal gland, left kidney, and colon with splenic vessel invasion.

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  Fig. 2 (A, B) Abdominopelvic computed tomography after administration of the 10th doses of modified FOLFIRINOX, showing decreased size and solidity of mass (arrow).

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  Fig. 3 (A) SpA (long white arrow) and SpV (short white arrows) were ligated and celiac artery dissection was done. (B) Left adrenal gland was resected and left pararenal fat layer were dissected. Note LRA and LRV, as well as resected spelnic artery (long white arrow). (C) Laparoscopic wedge resection of the stomach was performed with endoscopic gastrointestinal anasomosis (GIA) stapler. (D) Segmental resection of the affected colon was done with GIA stapler. CHA, common hepatic artery; LGA, left gastric artery; SpA, splenic artery; SpV, splenic vein; SMV, superior mesenteric vein; IMV, inferior mesenteric vein; Sp, spleen; P, pancreas; Ad, adrenal gland; LRA, left renal artery; LRV, left renal vein; K, kidney; G, stomach; C, colon.

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  Fig. 4 Final pathology showed no residual carcinoma with cystic degeneration and necrosis.

Reference

1. Li D, Xie K, Wolff R, Abbruzzese JL. 2004; Pancreatic cancer. Lancet. 363:1049–1057. DOI: 10.1016/S0140-6736(04)15841-8. PMID: 21620466. PMCID: PMC3062508.

2. Varadhachary GR, Tamm EP, Abbruzzese JL, Xiong HQ, Crane CH, Wang H, et al. 2006; Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy. Ann Surg Oncol. 13:1035–1046. DOI: 10.1245/ASO.2006.08.011. PMID: 16865597.

3. Barenboim A, Lahat G, Geva R, Nachmany I, Nakache R, Goykhman Y, et al. 2018; Neoadjuvant FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer: an intention to treat analysis. Eur J Surg Oncol. 44:1619–1623. DOI: 10.1016/j.ejso.2018.07.057. PMID: 30146251.

4. Blazer M, Wu C, Goldberg RM, Phillips G, Schmidt C, Muscarella P, et al. 2015; Neoadjuvant modified (m) FOLFIRINOX for locally advanced unresectable (LAPC) and borderline resectable (BRPC) adenocarcinoma of the pancreas. Ann Surg Oncol. 22:1153–1159. DOI: 10.1245/s10434-014-4225-1. PMID: 25358667. PMCID: PMC4373613.

5. Nanda RH, El-Rayes B, Maithel SK, Landry J. 2015; Neoadjuvant modified FOLFIRINOX and chemoradiation therapy for locally advanced pancreatic cancer improves resectability. J Surg Oncol. 111:1028–1034. DOI: 10.1002/jso.23921. PMID: 26073887.

6. Hong SS, Hwang HK, Lee WJ, Kang CM. 2020; Feasibility and safety of laparoscopic radical distal pancreatosplenectomy with adrenalectomy in advanced pancreatic cancer. Ann Surg Oncol. 27:5235–5236. DOI: 10.1245/s10434-020-08670-9. PMID: 32474822.

7. Lorenzen S, Thuss-Patience P, Al-Batran SE, Lordick F, Haller B, Schuster T, et al. 2013; Impact of pathologic complete response on disease-free survival in patients with esophagogastric adenocarcinoma receiving preoperative docetaxel-based chemotherapy. Ann Oncol. 24:2068–2073. DOI: 10.1093/annonc/mdt141. PMID: 23592699.

8. Valeri S, Borzomati D, Nappo G, Perrone G, Santini D, Coppola R. 2014; Complete pathological response after FOLFIRINOX for locally advanced pancreatic cancer. The beginning of a new era? Case report and review of the literature. Pancreatology. 14:425–430. DOI: 10.1016/j.pan.2014.07.002. PMID: 25278312.

9. Luu AM, Herzog T, Hoehn P, Reinacher-Schick A, Munding J, Uhl W, et al. 2018; FOLFIRINOX treatment leading to pathologic complete response of a locally advanced pancreatic cancer. J Gastrointest Oncol. 9:E9–E12. DOI: 10.21037/jgo.2018.01.07. PMID: 29755782. PMCID: PMC5934161.

10. Cloyd JM, Heh V, Pawlik TM, Ejaz A, Dillhoff M, Tsung A, et al. 2020; Neoadjuvant therapy for resectable and borderline resectable pancreatic cancer: a meta-analysis of randomized controlled trials. J Clin Med. 9:1129. DOI: 10.3390/jcm9041129. PMID: 32326559. PMCID: PMC7231310.

11. Versteijne E, Vogel JA, Besselink MG, Busch ORC, Wilmink JW, Daams JG, et al. 2018; Meta-analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer. Br J Surg. 105:946–958. DOI: 10.1002/bjs.10870. PMID: 29708592. PMCID: PMC6033157.

12. Satoi S, Yamaue H, Kato K, Takahashi S, Hirono S, Takeda S, et al. 2013; Role of adjuvant surgery for patients with initially unresectable pancreatic cancer with a long-term favorable response to non-surgical anti-cancer treatments: results of a project study for pancreatic surgery by the Japanese Society of Hepato-Biliary-Pancreatic Surgery. J Hepatobiliary Pancreat Sci. 20:590–600. DOI: 10.1007/s00534-013-0616-0. PMID: 23660962.

13. Yoshida K, Iwashita T, Uemura S, Maruta A, Okuno M, Ando N, et al. 2017; A multicenter prospective phase II study of first-line modified FOLFIRINOX for unresectable advanced pancreatic cancer. Oncotarget. 8:111346–111355. DOI: 10.18632/oncotarget.22795. PMID: 29340058. PMCID: PMC5762326.

14. Shin SH, Kim SC, Song KB, Hwang DW, Lee JH, Lee D, et al. 2015; A comparative study of laparoscopic vs. open distal pancreatectomy for left-sided ductal adenocarcinoma: a propensity score-matched analysis. J Am Coll Surg. 220:177–185. DOI: 10.1016/j.jamcollsurg.2014.10.014. PMID: 25529901.

15. de Rooij T, van Hilst J, van Santvoort H, Boerma D, van den Boezem P, Daams F, et al. 2019; Minimally invasive versus open distal pancreatectomy (LEOPARD): a multicenter patient-blinded randomized controlled trial. Ann Surg. 269:2–9. DOI: 10.1097/SLA.0000000000002979. PMID: 30080726.

16. Sui CJ, Li B, Yang JM, Wang SJ, Zhou YM. 2012; Laparoscopic versus open distal pancreatectomy: a meta-analysis. Asian J Surg. 35:1–8. DOI: 10.1016/j.asjsur.2012.04.001. PMID: 22726557.

17. Lee SH, Kang CM, Hwang HK, Choi SH, Lee WJ, Chi HS. 2014; Minimally invasive RAMPS in well-selected left-sided pancreatic cancer within Yonsei criteria: long-term (>median 3 years) oncologic outcomes. Surg Endosc. 28:2848–2855. DOI: 10.1007/s00464-014-3537-3.

18. Lee SH, Hwang HK, Kang CM, Lee WJ. 2017; The Yonsei criteria as a clinically detectable parameter for excellent prognosis in resected left-sided pancreatic cancer: outcomes of a propensity score-matched analysis. Surg Endosc. 31:4656–4664. DOI: 10.1007/s00464-017-5529-6. PMID: 28389802.

19. Lee SH, Kang CM, Kim H, Hwang HK, Song SY, Seong J, et al. 2015; Pathological complete remission of pancreatic cancer following neoadjuvant chemoradiation therapy; not the end of battles. Medicine (Baltimore). 94:e2168. DOI: 10.1097/MD.0000000000002168. PMID: 26717359. PMCID: PMC5291600.

20. Chaudhary P. 2015; Acinar cell carcinoma of the pancreas: a literature review and update. Indian J Surg. 77:226–231. DOI: 10.1007/s12262-014-1049-y. PMID: 26246707. PMCID: PMC4522262.