Local radicality and survival outcome of pancreatic cancer surgery

Abstract

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.

Systematic Analysis of Accuracy in Predicting Complete Oncological Resection in Pancreatic Cancer Patients—Proposal of a New Simplified Borderline Resectability Definition

“…R0 resection is the major outcome parameter in borderline resectable patients, and R status is one of the most important prognostic parameters in pancreatic cancer patients [27][28][29]. However, the current study is the first, to our knowledge, evaluating the accuracy of different borderline definition criteria in predicting R status.…”

“…The Leeds/Wittekind protocol used in Europe involves a circumferential assessment of all tumor margins, and a distinction is made between "R0 narrow", with less than 1 mm distance between tumor cells and the resection margin, and "R0 wide", showing a minimum distance of 1 mm between tumor cells and the resection margin [30,31]. Several studies and meta-analyses have demonstrated improved overall survival rates following R0 wide resections as compared to R0 narrow and R1 resections [27,32,33]. The novel borderline definition criteria show a moderate sensitivity in predicting UICC/AJCC R status and a high sensitivity in predicting Leeds/Wittekind circumferential margin status.…”

Perioperative glucocorticoids are associated with improved long-term survival after pancreatic cancer surgery: A retrospective cohort study

“…However, even after radical resection and modern chemotherapy, long-term prognosis of pancreatic cancer patients remains poor. According to recent studies, the median recurrence-free survival after pancreatic cancer surgery (and chemotherapy) was 6.7-22.9 months, the median overall survival was 10.9-54.4 months, and the 5-year survival rate was 7.3-44.1% [3,4]. In the present study, the median recurrence-free survival was 9.4 months (95% CI 5.1-20.3), the median overall survival was 16.8 months (95% CI 10.4-29.2), and the 5-year survival rate was 11.1% (95% CI 6.2-16.0).…”

“…Currently, surgical resection accompanied by systemic adjuvant chemotherapy is the only possible treatment for patients to achieve prolonged survival [3]. However, recent evidence showed that, even after radical resection and modern adjuvant chemotherapy, the clinical outcome of pancreatic cancer remains poor, with a median overall survival time of 28-54 months [4]. Recurrence and metastasis are the main reasons leading to short survival of patients after pancreatic cancer surgery.…”

“…Recurrence and metastasis are the main reasons leading to short survival of patients after pancreatic cancer surgery. This is because that the pancreatic cancer cells invade the lymphatic system and form micro-metastases at the very early stage, which make radical resection incomplete [4]. What's more, surgery-related inflammation will promote tumor growth and metastasis [5].…”