Surgical strategies and novel therapies for locally advanced pancreatic cancer

Abstract

Many patients with pancreatic cancer are not candidates for surgical resection due to involvement of critical mesenteric vascular structures. We compare and contrast the commonly used classification systems for borderline resectable and locally advanced pancreatic cancer. We describe the current strategies in managing venous and arterial involvement, as well as the role of neoadjuvant chemotherapy and chemoradiation, before explanding on a novel clinical trial in this patient population.

Multidisciplinary management of locally advanced pancreatic adenocarcinoma: Biology is King

“…However, more recent studies from high‐volume centers have demonstrated similar outcomes between patients undergoing venous resection and reconstruction and patients with more easily resectable tumors 60,61 . An MD Anderson study of 141 patients concluded that vein reconstruction (VR) did not alter median survival rates (23.4 months vs. 26.5 months without VR) suggesting that venous involvement was more a function of the vein as a bystander than aggressive underlying biology 62,63 . These findings highlight the importance of patient selection and of the experience needed to perform these procedures, both of which lead to better outcomes.…”

“…This makes the SMA margin, also known as the uncinate or retroperitoneal margin, the most commonly positive margin during a pancreatectomy 64 . Most studies investigating the feasibility and benefit of arterial resection and reconstruction (ARR) in LAPC are small and difficult to generalize 63 . A 2011 meta‐analysis including 26 studies and 2243 patients found an increase in the rates of perioperative mortality and poor long‐term outcomes (decreased survival at 1 and 3 years) in patients undergoing ARR compared with patients who did not undergo ARR (OR 5.04; p < .0001).…”

A proposal for the ideal algorithm for the diagnosis, staging, and treatment of pancreas masses suspicious for pancreatic adenocarcinoma: Results of a working group of the Canadian Society for Endoscopic Ultrasound

“…[ 57 ] A chemotherapy up-front approach has already become the gold standard for borderline-resectable, or locally-advanced pancreas cancers. [ 59 ] Indeed, patients with tumours considered unresectable may become resectable in 10%–20% of cases with an upfront treatment strategy with chemotherapy with or without radiation. [ 59 ] At the 2018 American Society of Clinical Oncology meeting a prospective randomized controlled trial comparing chemotherapy and radiation prior to surgery, to upfront surgery for resectable pancreas cancer demonstrated improvement in median overall survival, time until PC recurrence, and the chance of surviving longer than 2 years was higher with preoperative treatment.…”

Pancreaticoduodenectomy With Venous Resection: An Analysis of 30-Day Morbidity and Mortality

“…These factors promote a high risk of neoplastic invasion of these vascular structures (6)(7)(8)(9) . Resection of vascular structures adjacent to the organ, even in cases of extensive invasion, has been practiced in recent years, but its perioperative outcomes are still poorly understood in our context, in addition to its impact on overall and disease-free survival (10)(11)(12) .…”