ORIGINAL ARTICLE – PANCREATIC TUMORS
FOLFIRINOX Versus Gemcitabine/Nab-Paclitaxel
for Neoadjuvant Treatment of Resectable and Borderline
Resectable Pancreatic Head Adenocarcinoma
Mashaal Dhir, MD
, Mazen S. Zenati, MD, PhD
, Ahmad Hamad, MD
, Aatur D. Singhi, MD
, Nathan Bahary, MD
Melissa E. Hogg, MD
, Herbert J. Zeh III, MD
, and Amer H. Zureikat, MD, FACS
Department of Surgery, SUNY Upstate Medical University, Syracuse, NY;
Department of Biostatistics and
Epidemiology, University of Pittsburgh, Pittsburgh, PA;
Department of Surgery, University of Pittsburgh Medical Center,
Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA;
Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA;
Division of Surgical Oncology, University of
Pittsburgh Medical Center, Pittsburgh, PA
Background. Both FOLFIRINOX and gemcitabine/nab-
paclitaxel (G-nP) are used increasingly in the neoadjuvant
treatment (NAT) of pancreatic ductal adenocarcinoma
(PDA). This study aimed to compare neoadjuvant FOL-
FIRINOX and G-nP in the treatment of resectable (R) and
borderline resectable (BR) head PDA.
Methods. A single-institution retrospective review of R
and BR patients undergoing pancreaticoduodenectomy
after NAT with FOLFIRINOX or G-nP was performed.
Comparative analysis was performed using inverse-proba-
bility-weighted (IPW) estimators. The end points of the
study were overall survival (OS) and an 80% reduction in
CA19-9 with NAT.
Results. In this study, 193 patients were analyzed, with 73
patients receiving FOLFIRINOX and 120 patients receiv-
ing G-nP. The median OS was 38.7 months for
FOLFIRINOX versus 28.6 months for G-nP (p = 0.214).
The patients who received FOLFIRINOX were younger
and had fewer comorbidities, more BR disease, and larger
tumors than those treated with G-nP (all p \ 0.05). The
two regimens were equally effective in achieving an 80%
decline in CA19-9 (p = 0.8). The R0 resection rates were
similar (80%), but FOLFIRINOX was associated with a
reduction in pN1 disease (56% vs. 72%; p = 0.028). The
receipt of adjuvant therapy was similar (74 vs. 75%;
p = 0.79). In the Cox regression analysis with adjustment
for baseline and treatment-related variables (FOLFIRINOX
vs. G-nP, age, gender, computed tomography (CT) tumor
size, BR vs. R, pre-NAT CA19-9), regimen type was not
associated with a survival beneﬁt. In the IPW analysis of
166 patients, however, the average treatment effect of
FOLFIRINOX was to increase OS by 4.9 months com-
pared with G-nP (p = 0.012).
Conclusions. Both FOLFIRINOX and G-nP are viable
options for neoadjuvant treatment of PDA. In this study,
neoadjuvant FOLFIRINOX was associated with a 4.9-
month improvement in survival compared with G-nP after
adjustment for covariates.
Pancreatic cancer is among the leading causes of cancer-
related mortality, with an estimated 53,670 new cases and
an estimated 43,090 deaths in 2017.
chemotherapy remains the standard treatment for pancre-
nearly 50% of pancreaticoduodenectomy (PD)
patients are unable to receive it due to postoperative
complications and a decline in performance status.
in addition to the beneﬁts of treating early micrometastatic
disease and assessing the chemo-responsiveness of tumors,
has resulted in a shift toward neoadjuvant systemic therapy
for resectable and borderline resectable disease.
Electronic supplementary material The online version of this
article (https://doi.org/10.1245/s10434-018-6512-8) contains
supplementary material, which is available to authorized users.
Ó Society of Surgical Oncology 2018
First Received: 24 January 2018;
Published Online: 14 May 2018
A. H. Zureikat, MD, FACS
Ann Surg Oncol (2018) 25:1896–1903