An aggressive therapeutic approach to carcinoma of the body and tail of the pancreas

Abstract

BACKGROUND Prognosis of patients with adenocarcinoma of the pancreatic body and tail is extremely poor. Anatomically, this part of the pancreas is thin, and cancerous invasion to the retropancreatic structures occurs easily. The majority of patients have residual tumor in the retroperitoneal tissues after conventional distal pancreatectomy. METHODS Between 1962 and 1979, 10 patients with carcinoma of the pancreatic body underwent simple distal pancreatectomy. Between 1980 and 1990, 22 patients including 7 with distant metastasis underwent a more aggressive approach intended to achieve longer survival: distal pancreatectomy with extended dissection of the lymph nodes and adjacent structures, especially into the retropancreatic space. After 1984, intraoperative radiation (IORT) by electron beam and chemotherapy by hepatic infusion plus systemic injection of mitomycin C (MMC) were added for 7 patients without distant metastasis. RESULTS The 10 patients who underwent pancreatectomy between 1962 and 1979 all died within 20 months after their operations. Conversely, the patients treated with an aggressive approach between 1980 and 1990 survived longer; the 5‐year survival rate for 15 patients without distant metastasis was 29%, though the 7 patients with distant metastasis died within 10 months of their operations. There were 4 long term survivors (;ce5 years); 3 of whom received IORT and chemotherapy with MMC. Invasion to the retropancreatic soft tissues was present in 95% of the resected specimens from the 22 patients. However, invasion to the surgical margin at the posterior surface of the resected specimen was present in only 36% after extended resection of the retropancreatic structures. CONCLUSIONS Survival improved for this disease after distal pancreatectomy with extended dissection, especially of the retropancreatic structures, adjuvant IORT, and chemotherapy had been performed. Cancer 1996;77:2325‐31.

Prognostic significance of angiogenesis in human pancreatic cancer

“…Based on the high rate of recurrence, surgery alone seems to be inadequate for the treatment of patients with pancreatic cancer. Indeed, new clinical approaches such as, for example adjuvant chemotherapy plus radiation therapy (chemoradiation) after surgery or before surgery have been attempted and only a little improvement was observed in the survival rates of patients with pancreatic cancer, but the prognosis has remained worse than other cancers, such as breast cancer, colon cancer and gastric cancer (Ozaki et al, 1996;Schnall et al, 1996;Kamthan et al, 1997). In addition, most patients with pancreatic cancers are already unresectable when they are initially diagnosed.…”

Results of radical distal pancreatectomy with en bloc resection of the celiac artery for locally advanced cancer of the pancreatic body

“…The long-term results of radical distal pancreatectomy with en bloc resection of the celiac artery, with 1-and 2-year survival rates of 51% and 14% and the median survival of 12.2 months are not satisfactory, although they are significantly better than those of palliative surgery and are similar to reported survival in less advanced tumors [1][2][3][4]6,7,18]. The fact that the majority of treatment failures were due to hepatic metastases indicates a need for more effective adjuvant therapy against hepatic metastases.…”

“…Previous studies reported that the rates of positive microscopic margins were 32 to 64% [4,5,7] and retroperitoneal recurrence accounted for 78 to 83% [6,18] of all recurrences, despite less advanced local disease. It has been suggested that this operation may help control local spread of advanced cancer of the body of the pancreas.…”

“…Most of cancers of the body and tail of the pancreas are discovered at a far advanced stage due to the lack of any specific signs or symptoms, such as obstructive jaundice caused by cancers of the head of the pancreas, and curative resection rates remain less than 22% [1][2][3][4][5][6][7][8]. Especially in cancers of the body of the pancreas, extrapancreatic extension often involves the celiac artery and/or the common hepatic artery, which are anatomically contiguous with the body of the pancreas.…”

“…Since Nimura et al's report [9], however, several authors have performed a radical distal pancreatectomy with en bloc resection of the celiac and common hepatic arteries for these locally advanced cancers [4,[10][11][12][13]. Despite reports of a few long-term survivors [4,10,13], the overall survival benefit and the risks of this challenging operation are unknown because previous reports have included only a small number of patients (Miyakawa et al [13]: n=8, Mayumi et al [10]: n=6, Konishi et al [12]: n=4, and Ozaki et al [4]: n=2).…”