Resection After neoadjuvant therapy for locally advanced, “unresectable” pancreatic cancer

Department of Surgery, University Hospital Heidelberg, Heidelberg, Germany.
Surgery (Impact Factor: 3.38). 07/2012; 152(3 Suppl 1):S33-42. DOI: 10.1016/j.surg.2012.05.029
Source: PubMed


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.

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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 [4]. 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 [5] [6], (ii) determination of liver volumes and estimation of hypertrophy degree of the future liver remnant (FLR) [2] [7] [8], (iii) surgical planning of hepatic resection centered on the anatomical relationship of the tumor (vascular structures) [2] and radiological staging to increase the rate of resection with curative purpose [2] [9], (iv) evaluation of biological tumour response to neoadjuvant/adjuvant chemotherapy [10], (v) patients' followup after surgical resection. "
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    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.
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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. "
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    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.
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