title: Neoadjuvant therapy is associated with a reduced lymph node ratio in patients with potentially resectable pancreatic cancer.
abstract: BACKGROUND
  The use of neoadjuvant therapy (NAC) for the treatment of potentially resectable pancreatic cancer remains controversial. In this study, we sought to evaluate cancer-specific endpoints in patients undergoing a NAC versus a surgery-first (SF) approach with specific emphasis on lymph node metastases.
  
  
  METHODS
  A total of 222 patients who underwent NAC and 85 patients who underwent SF were identified from 1990 to 2008 and compared for cancer-related endpoints. Peripancreatic lymph nodes from 135 neoadjuvant therapy patients were evaluated for histologic tumor regression.
  
  
  RESULTS
  Patients who underwent NAC followed by surgery had improved overall survival and time to local recurrence compared with the SF approach. NAC patients were less likely to have lymph node metastases (p = 0.001), lymphovascular invasion (LVI), and had smaller tumors. On multivariate analysis, lymph node positivity was associated with SF, tumor size, and the presence of LVI. NAC patients with N0 disease had equivalent outcomes to patients with a low-LNR (0.01-0.15), whereas patients with a LNR >0.15 had reduced survival, and time to local and distant recurrence. Ten of 135 (7.4 %) NAC patients had evidence of tumor regression in at least one lymph node.
  
  
  CONCLUSIONS
  Patients with potentially resectable PDAC selected to undergo NAC had improved survival and longer time to recurrence. Although some of these differences may be related to improvements in multimodality therapy completion rates, tumor regression in lymph node metastases exists and may demonstrate a biologic benefit of NAC compared with a SF approach.
authors.affiliation: Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.
authors.forename: Christina L
authors.initials: CL
authors.lastname: Roland
authors.forename: Anthony D
authors.initials: AD
authors.lastname: Yang
authors.forename: Matthew H G
authors.initials: MH
authors.lastname: Katz
authors.forename: Deyali
authors.initials: D
authors.lastname: Chatterjee
authors.forename: Huamin
authors.initials: H
authors.lastname: Wang
authors.forename: Heather
authors.initials: H
authors.lastname: Lin
authors.forename: Jean N
authors.initials: JN
authors.lastname: Vauthey
authors.forename: Peter W
authors.initials: PW
authors.lastname: Pisters
authors.forename: Gauri R
authors.initials: GR
authors.lastname: Varadhachary
authors.forename: Robert A
authors.initials: RA
authors.lastname: Wolff
authors.forename: Christopher H
authors.initials: CH
authors.lastname: Crane
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Lee
authors.forename: Jason B
authors.initials: JB
authors.lastname: Fleming
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000556:secondary / Q000628:therapy*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D021441:Carcinoma, Pancreatic Ductal / Q000401:mortality / Q000556:secondary / Q000628:therapy*; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D060787:Neoplasm Grading; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D009367:Neoplasm Staging; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D011379:Prognosis; D015996:Survival Rate