Resection after neoadjuvant therapy for locally advanced, "unresectable" pancreatic cancer
ABSTRACT For pancreatic cancer, complete macroscopic resection in combination with chemotherapy is the only potentially curative treatment. Many patients present with locally advanced cancers deemed unresectable. We sought to assess the results of exploration after neoadjuvant therapy for locally advanced possibly unresectable pancreatic cancer.
From a prospective database, all consecutive patients undergoing operation from October 2001 to December 2009 after neoadjuvant therapy for locally advanced pancreatic cancer were identified. Main criteria for "unresectability" were infiltration of the celiac axis or superior mesenteric artery. Resection rates, perioperative results, and survival were analyzed.
Of 257 patients, 199 (77.4%) had received neoadjuvant chemoradiation, and 58 (22.6%) chemotherapy only. Of 257 patients, 120 (46.7%) underwent successful resection, whereas 137 patients underwent exploration only; 47 (39.2%) multivisceral and 45 (37.5%) vascular resections (12 arterial reconstructions) were performed. There were 6 (5%) ypT0 neoplasms, 36 (30.0%) R0, 61 (50.8%) R1, and 16 (13.3%) R2 resections. The median follow-up of surviving patients (n = 22) was 22 months. Median postoperative survival was greater after resection (12.7 months) than after exploration alone (8.8 months; P < .0001). Median postoperative survival was 24.6 months after R0, 11.9 months after R1, and 8.9 months after R2 resection. The 3-year survival rate after R0 resection was 24%. To determine survival after start of neoadjuvant therapy, 3.7 months (median) have to be added.
In locally advanced, unresectable pancreatic cancer, R0/R1 resections can be achieved in up to 40% of patients who undergo operation after neoadjuvant therapy. In these cases, survival rates are similar to those observed for initially resectable pancreatic cancer.
- SourceAvailable from: Eduardo de Santibañes
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- "Hepatobiliary tumor that invade splacnic organs: hepatocarcinoma, cholangiocarcinoma, gallbladder carcinoma, hepatic sarcomas, and other mesenchymal tumors hepatic artery, superior mesenteric artery, and aorta) to select candidates for neoadjuvant treatment . They are valuable as well for the: (i) assessment of liver tumor load (size, number of lesions, etc.) and evaluation of peritoneal and extrahepatic disease  , (ii) determination of liver volumes and estimation of hypertrophy degree of the future liver remnant (FLR)   , (iii) surgical planning of hepatic resection centered on the anatomical relationship of the tumor (vascular structures)  and radiological staging to increase the rate of resection with curative purpose  , (iv) evaluation of biological tumour response to neoadjuvant/adjuvant chemotherapy , (v) patients' followup after surgical resection. "
ABSTRACT: Background. Combined liver and multivisceral resections are infrequent procedures, which demand extensive experience and considerable surgical skills. Methods. An electronic search of literature related to this topic published before June 2013 was performed. Results. There is limited scientific evidence of the feasibility and clinical outcomes of these complex procedures. The majority of these cases are simultaneous resections of colorectal tumors with liver metastases. Combined liver and multivisceral resections can be performed with acceptable postoperative morbidity and mortality rates only in carefully selected patients. Conclusion. Lack of experience in these aggressive surgeries justifies a careful selection of patients, considering their comorbidities.HPB Surgery 02/2014; 2014:7. DOI:10.1155/2014/976546
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- "Many cases which were not candidates for surgical resection previously are now offered surgical resection within the framework of studies analyzing the effect of neoadjuvant therapy in PDAC. Such cases are especially prone to postoperative complications due to extensive surgery, frequent vascular resections, and due to the negative impact of preoperative radio/chemotherapy on healing, which has already been shown in other tumors (Allendorf et al., 2008; Stumpf et al., 2009; Strobel et al., 2012; Vande Walle et al., 2012). The information on pancreatic stroma after radiotherapy is very limited. "
ABSTRACT: Our understanding of pancreatic ductal adenocarcinoma (PDAC) is shifting away from a disease of malignant ductal cells-only, toward a complex system where tumor evolution is a result of interaction of cancer cells with their microenvironment. This change has led to intensification of research focusing on the fibrotic stroma of PDAC. Pancreatic stellate cells (PSCs) are the main fibroblastic cells of the pancreas which are responsible for producing the desmoplasia in chronic pancreatitis (CP) and PDAC. Clinically, the effect of desmoplasia is two-sided; on the negative side it is a hurdle in the diagnosis of PDAC because the fibrosis in cancer resembles that of CP. It is also believed that PSCs and pancreatic fibrosis are partially responsible for the therapy resistance in pancreatic cancer. On the positive side, a fibrotic pancreas is safer to operate on compared to a fatty and soft pancreas which is prone for postoperative pancreatic fistula. In this review the impact of pancreatic fibrosis on diagnosis of pancreatic cancer and surgical decisions are discussed from a clinical point of view.Frontiers in Physiology 10/2012; 3:389. DOI:10.3389/fphys.2012.00389 · 3.50 Impact Factor
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ABSTRACT: BACKGROUND: Local recurrence of pancreatic cancer occurs in 80 % of patients within 2 years after potentially curative resections. Around 30 % of patients have isolated local recurrence (ILR) without evidence of metastases. In spite of localized disease these patients usually only receive palliative chemotherapy and have a short survival. PURPOSE: To evaluate the outcome of surgery as part of a multimodal treatment for ILR of pancreatic cancer. METHODS: All consecutive operations performed for suspected ILR in our institution between October 2001 and October 2009 were identified from a prospective database. Perioperative outcome, survival, and prognostic parameters were assessed. RESULTS: Of 97 patients with histologically proven recurrence, 57 (59 %) had ILR. In 40 (41 %) patients surgical exploration revealed metastases distant to the local recurrence. Resection was performed in 41 (72 %) patients with ILR, while 16 (28 %) ILR were locally unresectable. Morbidity and mortality were 25 and 1.8 % after resections and 10 and 0 % after explorations, respectively. Median postoperative survival was 16.4 months in ILR versus 9.4 months in metastatic disease (p < 0.0001). In ILR median survival was significantly longer after resection (26.0 months) compared with exploration without resection (10.8 months, p = 0.0104). R0 resection was achieved in 18 patients and resulted in 30.5 months median survival. Presence of metastases, incomplete resection, and high preoperative CA 19-9 serum values were associated with lesser survival. CONCLUSIONS: Resection for isolated local recurrence of pancreatic cancer is feasible, safe, and associated with favorable survival outcome. This concept warrants further evaluation in other institutions and in randomized controlled trials.Annals of Surgical Oncology 12/2012; 20(3). DOI:10.1245/s10434-012-2762-z · 3.94 Impact Factor