Radical Resection for Locally Advanced Pancreatic Cancers in the Era of New Neoadjuvant Therapy—Arterial Resection, Arterial Divestment and Total Pancreatectomy

Abstract

Aggressive arterial resection (AR) or total pancreatectomy (TP) in surgical treatment for locally advanced pancreatic cancer (LAPC) had long been discouraged because of their high mortality rate and unsatisfactory long-term outcomes. Recently, new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for LAPC and discuss the rationale of such an aggressive approach in the treatment of PC. AR for LAPCs is divided into three, according to the target vessel. The hepatic artery resection is the simplest one, and the reconstruction methods comprise end-to-end, graft or transposition, and no reconstruction. Celiac axis resection is mainly done with distal pancreatectomy, which allows collateral arterial supply to the liver via the pancreas head. Resection of the superior mesenteric artery is increasingly reported, though its rationale is still controversial. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In conclusion, more and more aggressive pancreatectomy has become justified by the principle of total neoadjuvant therapy. Further technical standardization and optimal neoadjuvant strategy are mandatory for the global dissemination of aggressive pancreatectomies.

Impact of resection margin status on survival after operation for pancreatic head cancer with extrapancreatic nerve plexus invasion

“…Phase III randomized controlled trials revealed that extended lymphadenectomy with dissection of the nerve plexus did not prolong patient survival after resection 8–10 . In addition, effectiveness of SMA resection with pancreaticoduodenectomy in improving prognosis for head‐PDAC with SMA involvement has not been clarified 35 . Therefore, not only radical resection but also minimal postoperative complication leading to adjuvant chemotherapy are necessary to improve the prognosis of head‐PDAC with PL invasion.…”

“…[8][9][10] In addition, effectiveness of SMA resection with pancreaticoduodenectomy in improving prognosis for head-PDAC with SMA involvement has not been clarified. 35 Therefore, not only radical resection but also minimal postoperative complication leading to adjuvant chemotherapy are necessary to improve the prognosis of head-PDAC with PL invasion. We also found a significant difference in DFS between the PL+ group and the PL− group; however, there was no significant difference in OS among these groups.…”

A more radical perspective on surgical approach and outcomes in pancreatic cancer—a narrative review

“…Arterial invasion when talking about pancreatic head tumors mainly implicate the SMA or HA. Reconstruction can be performed as end-to-end anastomosis or through the use of conduits, such as interposition grafts (74). Particularly useful is the splenic artery that can serve both for interposition or transposition in several complex reconstruction strategies (75).…”

Early Recurrence After Resection of Locally Advanced Pancreatic Cancer Following Induction Therapy

“…The majority of patients, however, are diagnosed at an advanced, unresectable stage with either systemic spread to distant organs or extensive local vascular tumor involvement 1. Advancements in systemic treatment and surgical techniques have increased the resection rate of the latter group, classified as locally advanced pancreatic cancer (LAPC) 8,10–12…”