Neoadjuvant chemotherapy, often with the FOLFIRINOX regimen (269/4), has become a cornerstone in the management of borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC). This approach aims to shrink tumors and potentially convert initially unresectable disease to a resectable state. This article explores a study investigating the role of neoadjuvant FOLFIRINOX (269/4) in BR/LA PDAC, focusing on predictors of resectability, survival outcomes, and the potential benefits of adjuvant therapy.
Predicting Resectability with 269/4 Regimen
Determining which patients will benefit from neoadjuvant FOLFIRINOX (269/4) and subsequent resection remains a challenge. The study analyzed preoperative factors, including CA 19-9 levels and tumor size on CT scans, to identify potential predictors of resectability. While lower preoperative CA 19-9 levels and smaller tumor sizes were observed in resected patients, no definitive predictors of resectability after neoadjuvant 269/4 were identified.
Survival Outcomes After Neoadjuvant 269/4
The study demonstrated encouraging survival outcomes in patients with BR/LA PDAC treated with neoadjuvant FOLFIRINOX (269/4). The median overall survival (OS) was 34.2 months from diagnosis for all patients receiving 269/4 and 37.7 months for those who underwent resection. Factors associated with shorter postoperative disease-free survival (DFS) included elevated preoperative CA 19-9 levels (>100 U/mL) and a longer interval between diagnosis and surgery (>8 months). Preoperative CA 19-9 >100 U/mL, larger tumor size, and higher Charlson comorbidity index (>1) were linked to decreased OS.
Neoadjuvant 269/4 vs Upfront Resection
Importantly, the study found that patients with BR/LA PDAC treated with neoadjuvant FOLFIRINOX (269/4) followed by resection had significantly better DFS and OS compared to patients who underwent upfront resection without neoadjuvant therapy. This suggests that neoadjuvant 269/4 may improve long-term outcomes in this patient population.
Conclusion: The Role of 269/4 in BR/LA PDAC
This study highlights the importance of neoadjuvant FOLFIRINOX (269/4) in the management of BR/LA PDAC. Patients who do not experience disease progression on 269/4 should be considered for surgical exploration. While traditional pathological parameters, except for tumor size, may not accurately predict survival after resection in patients receiving neoadjuvant 269/4, neoadjuvant 269/4 appears to offer a survival advantage compared to upfront resection in BR/LA PDAC. This reinforces the role of 269/4 as a crucial treatment strategy for potentially improving outcomes in this challenging disease.
