Preoperative mFOLFIRINOX versus PAXG for stage I–III resectable and borderline resectable pancreatic ductal adenocarcinoma (PACT-21 CASSANDRA): results of the first randomisation analysis of a randomised, open-label, 2× 2 factorial phase 3 trial

Kumar M, Patil NS, Mohapatra N, Sindwani G, Dhingra U, Yadav A et al.
Ann Surg 2024; 279: 932-944.

A temporary shunt reduced intra-operative blood loss (P=0.004) and need for transfusion in this study of 60 procedures. The shunted patients were also more haemodynamically stable in the anhepatic phase, requiring less vasopressor support, with better postoperative renal function. There were no other differences in postoperative outcomes.

Comment: The observed advantages should improve outcomes, but perhaps the study was too small to be definitive.

Bang JY, Lakhtakia S, Thakkar S, Buxbaum JL, Waxman I, Sutton B et al, on behalf of the United States Pancreatic Disease Study Group.

Lancet Gastrohepatol 2024; 9: 22-33.

Seventy patients were included. Upfront necrosectomy resulted in fewer reinterventions (median 1 vs 2, P=0.003), but did not reduce mortality (none versus 2, respectively, P=0.22), or adverse events.

Comment: Smallish study, but indications of advantage for earlier intervention, rather than wait and see.

Labori KJ, Bratlie SO, Andersson B, Angelsen J-H, Biorserud C, Bjornsson B et al, for the Nordic Pancreatic Cancer Trial-1 study group.

Lancet Gastrohepatol 2024; 9: 205-217.

Survival after 18 months was not improved after neoadjuvant chemotherapy (73 per cent, versus 60 per cent in controls, P=0.050) in this study that included 140 patients.

Comment: Negative result here, but more data for a larger meta-analysis.