Futility in adenosquamous pancreatic cancer

Background: Adenosquamous carcinoma of the pancreas (ASCP) is a rare and aggressive subtype of pancreatic cancer with a dismal prognosis. Futility in ASCP has been inadequately studied. The aim is to assess the incidence of futility in ASCP cases within a European cohort. Methods: Retrospective, multicenter European study including all consecutive patients who underwent surgery for ASCP between 2010 and 2024. Inclusion criteria: patients operated for ASCP during the study period. Exclusion criteria: patients without a confirmed pathological diagnosis of ASCP, those who did not undergo surgery, or had extra-pancreatic disease. A pancreatectomy was considered futile if a patient died from postoperative complications within 90 days, or if cancer-related mortality or recurrence occurred within 6 months of the operation. Results: 194 patients from 29 hospitals in 11 European countries were studied. Surgeries included 125 pancreaticoduodenectomies, 59 left pancreatectomies, and 10 total pancreatectomies. Major complications were observed in 25.3% of patients. Postoperative mortality was 5.7%. The rate of futility was 47.9%. Eleven patients (11,8%) died from postoperative complications, 69 patients (74,2%) had recurrence, and 13 patients (14%) died within 6 months due to cancer. In the multivariate analysis, a positive retroperitoneal margin, lymphatic invasion, and not receiving chemotherapy were associated with futility. Conclusions: The futility observed in ASCP is notably high and related to a positive retroperitoneal margin, lymphatic invasion, and not receiving adjuvant chemotherapy. Defining futile patients with an international consensus definition is crucial and has significant implications for shared decision-making and care optimization.