General Surgery

Eight-variable post-FOLFIRINOX calculator stratifies survival in localized PDAC

This international cohort included 2338 patients with localized PDAC treated first-line with (m)FOLFIRINOX and then restaged. Eight factors independently predicted overall survival: baseline resectability, tumor site, WHO status, restaging metastases, post-induction CA19-9, CA19-9 change, post-induction tumor size, and tumor size change. These variables were combined into a web-based calculator that stratified patients into four risk groups with 3-year survival from 6.0% to 65.8%. The tool can aid prognosis counseling, selection for resection, and tailoring adjuvant therapy intensity after neoadjuvant FOLFIRINOX. 1

Major pathologic response after preop therapy in PDAC predicts excellent survival and limited adjuvant benefit

This multi-institution retrospective series analyzed 739 PDAC patients undergoing pancreatectomy after preoperative treatment using Evans grading. Major pathologic response (Evans III/IV) occurred in 11.5% and was associated with markedly longer overall survival (71.5 vs 40.9 months) and recurrence-free survival (55.5 vs 15.2 months). MPR remained an independent prognostic factor for overall survival on multivariable analysis. Among MPR patients, adjuvant chemotherapy did not significantly affect overall or recurrence-free survival and was not an independent prognostic factor. Chemoradiotherapy, preoperative duration ≥6 months, post-treatment normal CA19-9, and radiologic response predicted achieving MPR, informing neoadjuvant and postoperative discussions. 2

ORCHESTRA: extensive tumor debulking fails to improve survival in multiorgan mCRC

In this randomized trial, 382 patients with multiorgan mCRC responding or stable after oxaliplatin-based chemotherapy were assigned to chemotherapy alone or additional debulking. More than 80% debulking via surgery, radiotherapy, and/or ablation had to be technically feasible before randomization. Median overall survival was similar: 27.5 months with chemotherapy alone versus 30.0 months with debulking plus chemotherapy (adjusted HR 0.88; P = .26). Progression-free survival was also similar, but serious adverse events were more frequent with debulking (53% vs 39%; P = .006). These data argue against routine aggressive multivisceral debulking for multiorgan mCRC outside carefully selected oligometastatic settings. 3

Omitting axillary surgery in node-negative early breast cancer preserves survival with modestly higher axillary recurrence

This meta-analysis pooled seven randomized trials including 8806 patients with early breast cancer and clinically node-negative axillae. Omitting axillary surgery versus sentinel lymph node biopsy or axillary dissection did not worsen overall survival (OR 1.02; 95% CI 0.86-1.20) or disease-free survival. Axillary surgery significantly reduced axillary recurrence risk (OR 0.18; 95% CI 0.10-0.31), although absolute recurrence rates were low. Findings support omitting axillary surgery in carefully staged, node-negative patients when prioritizing functional outcomes and morbidity reduction. 4