Pattern and risk factors for postoperative recurrence in borderline resectable pancreatic cancer after upfront surgery

doi:10.3748/wjg.v32.i23.119613

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Observational Study

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastroenterol. Jun 21, 2026; 32(23): 119613
Published online Jun 21, 2026. doi: 10.3748/wjg.v32.i23.119613

Pattern and risk factors for postoperative recurrence in borderline resectable pancreatic cancer after upfront surgery

Han-Xuan Wang, Qing Zhao, Jin-Can Huang, Qiang He, Shao-Cheng Lyu, Ren Lang

Han-Xuan Wang, Qing Zhao, Jin-Can Huang, Qiang He, Shao-Cheng Lyu, Ren Lang, Division of Hepatobiliary and Pancreaticosplenic Surgery, Department of General Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China

Han-Xuan Wang, Qing Zhao, Jin-Can Huang, Qiang He, Shao-Cheng Lyu, Ren Lang, Clinical and Research Center for Pancreatic Cancer, Capital Medical University, Beijing 100020, China

Co-first authors: Han-Xuan Wang and Qing Zhao.

Co-corresponding authors: Shao-Cheng Lyu and Ren Lang.

Author contributions: Wang HX and Zhao Q performed the formal analysis and wrote the original draft, they contributed equally to this article, they are the co-first authors of this manuscript; Wang HX, Zhao Q, and Huang JC collected and integrated the data; Wang HX and Lyu SC designed the study; He Q, Lyu SC, and Lang R provided the study material; Lang R acquired the funding for study; Lyu SC and Lang R reviewed and edited the original draft they contributed equally to this article, they are the co-corresponding authors of this manuscript; and all authors thoroughly reviewed and endorsed the final manuscript.

Supported by the Clinical Research Incubation Project, Beijing Chao-Yang Hospital, Capital Medical University, No. CYFH202302.

Institutional review board statement: This study was approved by the Medical Ethics Committee of Beijing Chao-Yang Hospital, Capital Medical University, approval No. 2024-ke-512.

Informed consent statement: Collection and analysis of historical data got the verbal informed consent from patients.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: Data generated and/or analyzed during this study are accessible from the corresponding author for reasonable requests.

Corresponding author: Ren Lang, Professor, Division of Hepatobiliary and Pancreaticosplenic Surgery, Department of General Surgery, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing 100020, China. dr_langren123@126.com

Received: February 2, 2026
Revised: February 15, 2026
Accepted: March 10, 2026
Published online: June 21, 2026
Processing time: 127 Days and 12.6 Hours

Abstract

BACKGROUND

Postoperative recurrence is the main cause of treatment failure in borderline resectable pancreatic cancer (BRPC) patients. Elaborating patterns and risk factors for tumor recurrence can help clinicians tailor treatment decision, thereby improving the clinical outcome of these patients. However, although upfront surgery serves as an important treatment option for BRPC patients and can lead to distinct recurrence risks and patterns, the exact characteristics of postoperative recurrence in these patients were unclear.

AIM

To describe the pattern of postoperative recurrence and identify its risk factors in BRPC patients receiving upfront surgery.

METHODS

This retrospective study analyzed 216 BRPC patients receiving upfront surgeries. Preoperative data, surgical condition, pathology and postoperative prognosis were analyzed. Kaplan-Meier method was applied for survival comparison. Risk factors for disease-free survival (DFS) and tumor recurrence were identified with Cox and logistic regression. Fine-Gray analysis was applied to adjust for competing event. Restricted cubic splines were used to evaluate the dose-response correlation and receiver operating characteristic analysis was applied for determination of optimal cutoff value.

RESULTS

Of 72.7% patients experienced postoperative recurrence with a medium DFS of 11 months. Most recurrences occurred within postoperative year one, and liver was the most common recurrence site. Patients with early recurrence had decreased post-recurrence survival compared to late recurrence patients (P < 0.001). Preoperative [carcinoembryonic antigen (CEA), hazard risk (HR) = 1.021, 95% confidence interval (CI): 1.002-1.040, P = 0.029], tumor diameter (HR = 1.101, 95%CI: 1.003-1.320, P = 0.044), differentiation (HR = 0.662, 95%CI: 0.473-0.927, P = 0.016) and lymph node metastasis (HR = 1.491, 95%CI: 1.009-2.202, P = 0.045) were independent risk factors for DFS. Preoperative CEA [relative risk (RR) = 1.083, 95%CI: 1.008-1.163, P = 0.029], tumor diameter (RR = 1.236, 95%CI: 1.013-1.507, P = 0.037), differentiation (RR = 0.508, 95%CI: 0.271-0.951, P = 0.034) and lymph node metastasis (RR = 2.151, 95%CI: 1.007-4.297, P = 0.030) were independent risk factors for early recurrence. Vascular invasion extent showed limited association with postoperative recurrence.

CONCLUSION

Most postoperative tumor recurrences occurred in postoperative year one in BRPC patients receiving upfront surgery, and liver was the most common site of recurrence. Preoperative CEA, tumor size, differentiation and lymph node metastasis were risk factors for DFS and early postoperative recurrence.

Keywords: Borderline resectable pancreatic cancer; Upfront surgery; Tumor recurrence; Pattern; Risk factor

Core Tip: This study characterized the recurrence patterns in borderline resectable pancreatic cancer patients undergoing upfront surgery. It identified that early recurrence, predominantly liver metastasis within the first year, is a major challenge. Preoperative carcinoembryonic antigen level, tumor diameter, poor differentiation, and lymph node metastasis were identified as independent risk factors, whereas the extent of vascular invasion showed limited association. These findings improved the understanding of postoperative tumor recurrence in borderline resectable pancreatic cancer patients and would help clinicians make optimal treatment decision so as to improve the prognosis of these patients.