Surgical Outcomes from Nationwide Implementation of the International Best-Practice for Locally Advanced Pancreatic Cancer (PREOPANC-4) study
Thomas F Stoop, Leonard W F Seelen, Freek R van ‘t Land, Jacobien C M Scheepens, Mahsoem Ali, Anna C van der Hout, B Marion van der Kolk, Bert A Bonsing, Daan J Lips, Eric R Manusama, François E J A Willemsen, Freek Daams, Geert Kazemier, Gijs A Patijn, Ignace H de Hingh, Jan H Wijsman, Jennifer Schreinemakers, Joris I Erdmann, J Sven D Mieog, Joost M Klaase, Judith A C Rietjens, Koop Bosscha, Lysanne P M Beuk, Maarten W Nijkamp, Marcel den Dulk, Marnix P M Kop, Mike S L Liem, Misha Luyer, Martijn W J Stommel, Olivier R Busch, Sebastiaan Festen, Stefan Bouwense, Tom M Karsten, Tom W van Ravens, Ulff P Neumann, Vincent E de Meijer, Vincent B Nieuwenhuijs, Werner A Draaisma, Wouter Derksen, Thomas L Bollen, Bas Groot Koerkamp, Casper H J van Eijck, I Quintus Molenaar, Christopher L Wolfgang, Marco Del Chiaro, Matthew H G Katz, Thilo Hackert, Johanna W Wilmink, Hjalmar C van Santvoort, Roeland F de Wilde, Marc G Besselink, , Adriënne te Riele, Aniek Vlijm, Ankie van der Velden, Anne Bruynzeel, Anne M Stiggelbout, Anne-Marie Dietvorst, Annemarie S B Conijn-Mensink, Annebeth Haringhuizen, Anneke Roeterdink, Annette van Zweeden, Anouk van Asseldonk, Ammar A Javed, André Sterk, Annuska Schoorlemmer, Anja Stam, Aram van Brussel, Barbara M Zonderhuis, Bas Boekestijn, Bibi Martens, Brigitte Haberkorn, C Yung Nio, Celine Leenen, Daud Allajar, Deborah Reijnders-Tromp, Dirk-Jan de Groot, Els Wink-Van Gestel, Emile D Kerver, Eran van Veldhuisen, Eva Versteijne, Evelien van Alphen, Evert van den Broek, Geert A Cirkel, Geertjan van Tienhoven, Geeske Heringa, Gert Stockmans, Gian Piero Serafino, Hannàh N Lelieveld-Rier, Hanneke W M van Laarhoven, Hanneke Zuetenhorst, Haske van Veenendaal, Hetty van Mierlo, Ingeborg Griffioen, Ingmar F Rompen, Irene E G van Hellemond, Iryna Symarska, Jacques Peters, Jan-Willem B de Groot, Jeanette Ham, Jeroen Willems, Jessica Coes, Joachim Kikomeko, Johan van Rooijen, Joanne Verheij, Joost Nederend, Mirte Streppel, José Schellekens, Kishan R D Lutchman, Judith de Vos-Geelen, Laura Moolenaar, Laurens van der Waaij, Laurens Beerepoot, Leonie J Mekenkamp, Lilly H J Brada, Lobke van Leeuwen - Snoeks, Lodewijk Brosens, Linda Garms, Leonieke W Kranenburg, Loes J Peters, Maartje Los, Marco B Polée, Marjolein Y V Homs, Marit Suttorp, Marieke S Walma, Marjon Oostdijk, Marleen Duizer, Melanie F M A Marting, Michael Doukas, Miriam L Wumkes, Monica Seijbel, Nicole D Hildebrand, Nynke M Michiels, Olaf Loosveld, Peter Nieboer, Ramon Bax, Roel Haen, Roel Heesakkers, Ronald M van Dam, Rosa van der Werf, Rowan van Gerven, Rune van de Wetering, Rutger T Theijse, Ruud Blankenburgh, Sandra Bakker, Sanne Achten, Saskia A C Luelmo, Simone Augustinus, Simone Rötgerink, Stijn Crobach, K C Khe Tran, Tess M E van Ramshorst, Wendy van der Deure-Gielisse, Wouter W te RieleAbstract
Background
In expert centers, surgical resection rates of locally advanced pancreatic cancer (LAPC) following induction chemotherapy have increased beyond 20% with subsequent 25% five-year overall survival (OS). In the Netherlands, however, the historical low 8% LAPC resection rate compared with 23% in international expert centers reflects relative reluctance. Thereby, opportunities to achieve long-term survival in appropriately selected patients may be missed. This study evaluated whether nationwide implementation of international multidisciplinary best-practice for LAPC management is feasible while maintaining surgical safety benchmarks (in-hospital/30-day major morbidity <50% and mortality ≤5%).
Methods
A multidisciplinary protocol was designed in collaboration with four international experts and prospectively implemented nationwide within the Dutch Pancreatic Cancer Group (DPCG) (2022-2024). This observational cohort included consecutive patients diagnosed with LAPC, defined by DPCG criteria. Eligible patients had radiologically non-progressive disease after at least four months of multi-agent chemotherapy. All patients who underwent resection were included in this safety analysis. A predefined sub-group analysis included patients with National Comprehensive Cancer Network (NCCN) LAPC. Primary outcomes included in-hospital/30-day major morbidity (i.e., Clavien-Dindo grade ≥IIIa) and mortality. The expected number of resections was 53.
Results
Overall, 180 patients with LAPC underwent surgical exploration, of whom 155 (86%) underwent resection in 11 centers. Most (74%) resections were performed in the three LAPC surgical centers. Extended resections were performed in 77% of patients, including portomesenteric venous (60%), multivisceral (23%), and arterial (21%) resections. In-hospital/30-day major morbidity rate was 44% and mortality rate was 0.6%, both within pre-established safety benchmarks. Benchmarks were also reached for patients with NCCN LAPC (49% major morbidity, 2% mortality).
Conclusion
Nationwide implementation of the international best-practice for LAPC was feasible with nearly three times more resections performed than expected, while morbidity and mortality remained well within predefined safety benchmarks.