Feasibility and safety of distal pancreatectomy with en bloc celiac axis resection (DP-CAR) combined with neoadjuvant therapy for borderline resectable and unresectable pancreatic body/tail cancer

Yoshitomi, Hideyuki; Sakai, Nozomu; Kagawa, Shingo; Takano, Shigetsugu; Ueda, Atsuhiko; Kato, Atsushi; Furukawa, Katsunori; Takayashiki, Tsukasa; Kuboki, Satoshi; Miyzaki, Masaru; Ohtsuka, Masayuki

doi:10.1007/s00423-019-01775-0

Cited by 25 publications

(45 citation statements)

References 24 publications

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“…Our clinically relevant POPF rate after DP in neoadjuvant group was high (33.3%), but there are reports that percentage of clinically relevant POPF after DP with CA resection after neoadjuvant chemotherapy is 32% to 40%, comparable to our reports. [ 24 , 38 ] Clinically relevant POPF after conventional open DP at our institution was also 3.7%, [ 39 ] which is comparable to upfront DP in this study (4.3%). Neoadjuvant treatment may have influenced the incidence of POPF.…”

Section: Discussionsupporting

confidence: 70%

“…The pathologic outcomes of patients who responded to neoadjuvant chemotherapy showed that subsequent pancreatectomy with AR was associated with improved oncological outcomes in terms of the number of positive lymph nodes, positive lymph node ratio, lymphovascular invasion, and TNM stage. Similar R0 resection, pathologic arterial invasion, and perineural invasion were not expected results, but rate of pathologic arterial invasion after pancreatectomy was reported as 8.3% to 74.2% in previous studies, [ 7 , 8 , 16 , 24 ] which means that the pathologic results are not yet clear even if there is radiologic invasion. Currently, there are few cases where pancreatectomy is performed directly on LAPC, and this pancreatectomy with AR itself is a rare operation; further research on these pathological findings is needed.…”

Section: Discussionsupporting

confidence: 52%

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Arterial resection during pancreatectomy for pancreatic ductal adenocarcinoma with arterial invasion

et al. 2020

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Section: Discussionsupporting

confidence: 70%

Section: Discussionsupporting

confidence: 52%

Arterial resection during pancreatectomy for pancreatic ductal adenocarcinoma with arterial invasion

et al. 2020

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“…This procedure relies on arterial blood supply of liver and stomach by collateralization from the SMA via the gastroduodenal artery after resection of the celiac axis without reconstruction. Feasibility and acceptable safety with mortality rates of 3%‐8% after DP‐CAR were demonstrated in several single‐center observational studies . In a recent retrospective international multicenter study including 191 patients undergoing DP‐CAR, the 90‐day mortality rate was 5.5% at five high‐volume but as high as 18% at 18 low‐volume DP‐CAR centers, demonstrating the importance of experience with this rare and complex procedure .…”

Section: Surgical Techniques To Increase Local Radicality In Pancreatmentioning

confidence: 99%

“…In a multicenter study performed in 20 European centers in 12 countries, the median survival of 68 patients undergoing DP‐CAR was 18 months . A recent single‐center study reported a very favorable median survival of 38.6 months with a strategy of neoadjuvant therapy followed by DP‐CAR in pancreatic cancer with celiac axis involvement, recommending a neoadjuvant strategy in these patients . The literature on pancreatic cancer resections with arterial resections apart from DP‐CAR is restricted to case reports and small series with high risk of bias.…”

Section: Surgical Techniques To Increase Local Radicality In Pancreatmentioning

confidence: 99%

Local radicality and survival outcome of pancreatic cancer surgery

Niesen

Hank

Büchler

et al. 2019

Annals of Gastroent Surgery

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Pancreatic cancer remains a therapeutic challenge. Surgical resection in combination with systemic chemotherapy is the only option promising long‐term survival and potential cure. However, only about 20% of patients are diagnosed with tumors that are still in a resectable stage. Even after potentially curative resection and modern regimens for adjuvant chemotherapy, the majority of patients develop local and systemic recurrence resulting in median overall survival times of 28‐54 months. The predominance of systemic recurrence and its impact on survival may lead to the assumption that surgical radicality and local control play only minor roles in the treatment of pancreatic cancer. This review provides an overview of the recent literature on surgical radicality and survival outcome in pancreatic cancer. The current evidence on the extent of lymphadenectomy, the prognostic impact of the extent of lymph node involvement, and the impact of the resection margin status on postresection survival are reviewed. Data from recent studies performed in the context of modern surgery and adjuvant therapy provide good evidence of a considerable impact of local radicality on survival after pancreatic cancer surgery. Surgical techniques that have been developed to refine oncological resections and to increase local control as well as resectability are highlighted. These techniques include artery‐first approaches, level‐3 dissection with removal of the periarterial nerve plexus, the triangle operation, and extended resections. Local radicality and quality of surgical resection remain among the most important parameters that determine the chances for survival in patients with non‐metastatic pancreatic cancer.

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“…In spite of the technical feasibility of upfront DP-CAR, a neoadjuvant strategy may appear more promising in these tumors. An observational study on resection after NAT in a cohort of 31 patients with involvement of the celiac axis reported an R0 resection rate of 73% [82]. Severe complications were reported in 42%, with an in-hospital mortality of only one patient.…”

Section: Techniques For Conversion Surgery After Neoadjuvant Therapymentioning

confidence: 99%

Conversion Surgery for Advanced Pancreatic Cancer

Hank

Strobel

2019

JCM

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While primarily unresectable locally advanced pancreatic cancer (LAPC) used to be an indication for palliative therapy, a strategy of neoadjuvant therapy (NAT) and conversion surgery is being increasingly used after more effective chemotherapy regimens have become available for pancreatic ductal adenocarcinoma. While high-level evidence from prospective studies is still sparse, several large retrospective studies have recently reported their experience with NAT and conversion surgery for LAPC. This review aims to provide a current overview about different NAT regimens, conversion rates, survival outcomes and determinants of post-resection outcomes, as well as surgical strategies in the context of conversion surgery after NAT. FOLFIRINOX is the predominant regimen used and associated with the highest reported conversion rates. Conversion rates considerably vary between less than 5% and more than half of the study population with heterogeneous long-term outcomes, owing to a lack of intention-to-treat analyses in most studies and a high heterogeneity in resectability criteria, treatment strategies, and reporting among studies. Since radiological criteria of local resectability are no longer applicable after NAT, patients without progressive disease should undergo surgical exploration. Surgery after NAT has to be aimed at local radicality around the peripancreatic vessels and should be performed in expert centers. Future studies in this rapidly evolving field need to be prospective, analyze intention-to-treat populations, report stringent and objective inclusion criteria and criteria for resection. Innovative regimens for NAT in combination with a radical surgical approach hold high promise for patients with LAPC in the future.

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Feasibility and safety of distal pancreatectomy with en bloc celiac axis resection (DP-CAR) combined with neoadjuvant therapy for borderline resectable and unresectable pancreatic body/tail cancer

Cited by 25 publications

References 24 publications

Arterial resection during pancreatectomy for pancreatic ductal adenocarcinoma with arterial invasion

Arterial resection during pancreatectomy for pancreatic ductal adenocarcinoma with arterial invasion

Local radicality and survival outcome of pancreatic cancer surgery

Conversion Surgery for Advanced Pancreatic Cancer

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