Primary Tumor Resection Following Favorable Response to Systemic Chemotherapy in Stage IV Pancreatic Adenocarcinoma with Synchronous Metastases: a Bi-institutional Analysis

Introduction: Patients with metastatic pancreatic adenocarcinoma have traditionally been offered palliative chemotherapy alone, and the role of surgery in these patients remains unknown. Methods: A bi-institutional retrospective review was performed for patients with metastatic pancreatic adenocarcinoma who underwent resection of the primary tumor from 2008 to 2013. The primary outcome measured was postoperative overall survival. Secondary outcomes included postoperative disease-free survival and overall survival from the time of diagnosis. Results: Twenty-three patients were identified who met the study criteria with a median follow-up of 30 months. Metastatic sites included the liver (n = 16), the lung (n = 6), and the peritoneum (n = 2). Chemotherapy included FOLFIRINOX (n = 14) and gemcitabine-based regimens (n = 9), with a median of 9 cycles (range 2–31) prior to surgical treatment. Median time from diagnosis to surgery was 9.7 months (IQR 5.8–12.8). Median overall survival (OS) from surgery, disease-free survival, and OS from diagnosis were 18.2 months (95 % CI 11.8–35.5), 8.6 months (95 % CI 5.2–16.8), and 34.1 months (95 % CI 22.5–46.2), respectively. The 1- and 3-year OS from surgery were 72.7 % (95 % CI 49.1–86.7) and 21.5 % (95 % CI 4.3–47.2), respectively. Conclusion: Resection of the primary tumor in patients with metastatic pancreatic adenocarcinoma may be considered in highly selected patients with favorable imaging and CA 19-9 response following chemotherapy at high-volume centers providing multidisciplinary care. These patients should be enrolled in prospective clinical trials or institutional registries to better quantify the potential benefits of such a strategy.