Prognostic discrepancies between surgery-first and neoadjuvant-treated resected pancreatic cancer in the same pathological stage.

[PURPOSE] To compare survival outcomes between patients undergoing upfront surgery and those receiving neoadjuvant therapy followed by surgery for pancreatic cancer stratified by pathological stage.

[METHODS] We retrospectively analyzed data from 456 patients who underwent curative-intent pancreatectomy between 2011 and 2023. The study patients were categorized into upfront surgery (n = 290) and neoadjuvant therapy (n = 166) groups. The overall and disease-free survival rates were compared between the groups within each pathological stage. Univariate and multivariate analyses were performed for patients with Stage I disease.

[RESULTS] In Stage IA, overall and disease-free survival were significantly better in the upfront surgery group than in the neoadjuvant therapy group (P = 0.0022 and P = 0.0012, respectively). There were no significant differences between the groups in patients with Stage II disease. A multivariate analysis of patients with Stage I disease identified neoadjuvant therapy (HR: 4.053, P = 0.0010), biliary drainage (HR: 2.342, P = 0.0399), and absence of adjuvant chemotherapy (HR: 4.563, P = 0.0004) as independent predictors of poor overall survival.

[CONCLUSION] Even within the same pathological stage, the survival outcomes differed between the upfront surgery and neoadjuvant therapy groups. These findings suggest that treatment history should be considered when interpreting the pathological stage and assessing the prognosis of patients with pancreatic cancer.