Update on Post-Recurrence Survival After Pancreatic Cancer Resection: A Comprehensive Systematic Review

Background The burden of recurrence after resection of pancreatic-ductal-adenocarcinoma (PDAC) remains very high, leading to a dismal prognosis. Post-recurrence survival (PRS) and its determinants have been less studied compared to traditional outcomes like overall and recurrence-free survival. Aims To provide an update on PRS after PDAC resection and identify its prognostic determinants. Methods A PRISMA-compliant systematic literature review was performed, searching studies published in the period January 01/2010-12/2025 (PubMed/Scopus/Web of Science). The population, intervention, comparator, outcome (PICO) strategy was used to formulate study questions and select studies: Population/Intervention) original studies including patients who had resection of non-metastatic PDAC and specifically reporting PRS; Comparator) timing/pattern/treatment of recurrence; Outcomes) PRS defined as survival after PDAC recurrence, site- and treatment-specific PRS, predictors of PRS. Results Forty-five eligible studies were identified. Median PRS range was 2.6-44.0 months. Local recurrence (remnant pancreas or locoregional lymph nodes) and lung-limited recurrence had longer PRS (range, 5.0-20.0 months and 8.5-32.5 months respectively) compared to liver recurrence (range, 5.1-8.5 months). Peritoneal or multisite recurrence had the shortest PRS. Whenever oncologically/technically feasible, completion pancreatectomy (i.e., isolated local recurrence), and resection of limited recurrence in the lungs or regional/retroperitoneal lymph nodes were associated with longer PRS, compared to systemic treatment alone. Combined local and systemic treatment had a positive effect on PRS, compared to systemic chemotherapy alone. Prolonged PRS was associated with asymptomatic recurrence or low performance status, routine/active follow-up, longer recurrence-free survival after first pancreatectomy, lung-only/isolated local recurrence, resectable recurrence, young age, serum albumin and Ca19-9 levels at recurrence, adjuvant chemotherapy after index pancreatectomy. Conclusion PRS varies widely based on pattern/timing/treatment of recurrences. Systemic control of the disease is pivotal. Patients eligible for radical treatments (i.e., completion pancreatectomy) or showing favorable tumor biology (isolated lung recurrence), may achieve very long PRS. The impact of neoadjuvant therapy (before index pancreatectomy) on PRS is still unexplored.