# The Role of a “Conservative” Resection Strategy After Neoadjuvant Treatment for Borderline/Locally Advanced PDAC with Arterial Involvement: A Single-Centre Retrospective Observational Study

## TL;DR

A conservative surgery approach after neoadjuvant therapy for advanced pancreatic cancer is feasible and improves survival, but careful patient selection is crucial due to disease variability.

## Contribution

Demonstrates the feasibility and survival benefit of conservative resection with arterial divestment in borderline or locally advanced pancreatic cancer.

## Key findings

- Patients who underwent resection had a median overall survival of 33 months compared to 26 months for non-resected patients.
- Neoadjuvant folfirinox therapy significantly increased the odds of resection.
- Surgical resection and normalization of Ca 19,9 were associated with reduced mortality risk.

## Abstract

A conservative surgical approach with arterial divestment after neoadjuvant therapy in LAPC is feasible and associated with survival benefit, offering acceptable oncological outcomes. Careful patient selection remains essential given imaging limitations and the biological heterogeneity of the disease.

Background: Recent advances in multimodal therapies have increased the potential for resectability of borderline resectable and locally advanced pancreatic ductal adenocarcinoma (PDAC). We herein describe the conservative resection strategy adopted at our institution and the oncological outcomes of patients with PDAC and arterial involvement. Methods: This retrospective single-centre study included patients diagnosed with PDAC and radiologic evidence of arterial involvement who underwent surgical exploration between January 2014 and June 2024. All patients received induction chemotherapy (±radiotherapy). Survival outcomes were analyzed using the Kaplan–Meier and Cox proportional hazards models. Logistic regression analyses were used to identify predictors of resectability and recurrence. Results: A total of 76 patients were included: 59 underwent pancreatic resection with arterial divestment (AD) in case of persistent arterial involvement and 17 were deemed unresectable at laparotomy. Neoadjuvant folfirinox was significantly associated with increased odds of resection (HR = 3.23, 95% CI: 1.59–9.90, p = 0.040). Median overall survival from diagnosis was 33 months (29–39) in resected patients and 26 months (16–29) in non-resected patients (p = 0.0176). Surgical resection and Ca 19,9 normalization after induction therapy were associated with reduced mortality risk (HR = 0.38, 95% CI: 0.19–0.75, p = 0.005 and HR = 0.56, 95% CI: 0.35–0.88, p = 0.014, respectively). Conclusions: Despite a limited sample size and retrospective nature, these findings highlight the value of multimodal strategies in managing PDAC with arterial involvement. AD represents a valuable technique associated with acceptable outcomes in selected patients. Future interventional prospective studies are needed to optimize patient selection and validate the prognostic role of extended surgical procedures.