Advertisement

Commentary: Surgery for locally advanced pancreatic cancer after neoadjuvant therapy

Published:August 28, 2020DOI:https://doi.org/10.1016/j.surg.2020.07.024
      The relationship of tumors in the head, neck, and body of the pancreas to adjacent visceral vessels has become increasing complex with respect to staging and treatment, attributable to the improved responses observed with current neoadjuvant therapies. In this issue of Surgery, internationally known experts in the field from the United States and Europe comment on the technical aspects of arterial dissection (at the time of pancreatectomy), with special reference to the plane of dissection between the autonomic nerve and the adventitia of the artery.
      • Diener M.K.
      • Mihaljevic A.L.
      • Strobel O.
      • et al.
      Periarterial divestment in pancreatic cancer surgery.
      ,
      • Habib J.R.
      • Kinny-Köster B.
      • van Oosten F.
      • et al.
      Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: Surgical planning with the “halo sign” and the “string sign.”.
      For decades we have emphasized removal of the perineural and soft tissue to the right of the superior mesenteric artery (SMA) at the time of pancreaticoduodenectomy, and Tseng et al
      • Tseng J.F.
      • Raut C.P.
      • Lee J.E.
      • Pisters P.W.T.
      • et al.
      Pancreaticoduodenectomy with vascular resection: Margin status and survival duration.
      and Verbeke
      • Verbeke C.S.
      Resection margins in pancreatic cancer.
      have elegantly demonstrated how tumor cells can be left behind, often at a considerable distance from the boundaries of the gross tumor. A combination of optimal surgical technique (to include resection of the autonomic nerve adjacent to the visceral arteries) and preoperative radiation therapy (as part of the neoadjuvant treatment program) will minimize local recurrence.
      • Tsai S.
      • Christians K.K.
      • George B.
      • et al.
      A phase II clinical trial of molecular profiled neoadjuvant therapy for localized pancreatic ductal adenocarcinoma.
      It is important to note that local recurrence will become radiographically and clinically evident only if the patient survives the risk of early distant recurrence.
      • Barnes C.A.
      • Aldakkak M.
      • Christians K.K.
      • et al.
      Radiographic patterns of first disease recurrence after neoadjuvant therapy and surgery for patients with resectable and borderline resectable pancreatic cancer.
      Our approach to the visceral arteries as well as to the superior mesenteric vein-portal vein (SMV-PV) at the time of pancreatectomy for locally advanced pancreatic cancer has been recently published and emphasizes the importance of both treatment sequencing and the technical aspects of surgery based on tumor location.
      • Chatzizacharias N.A.
      • Tsai S.
      • Griffin M.
      • et al.
      Locally advanced pancreas cancer: Staging and goals of therapy.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Diener M.K.
        • Mihaljevic A.L.
        • Strobel O.
        • et al.
        Periarterial divestment in pancreatic cancer surgery.
        Surgery. 2021; 169: 1019-1025
        • Habib J.R.
        • Kinny-Köster B.
        • van Oosten F.
        • et al.
        Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: Surgical planning with the “halo sign” and the “string sign.”.
        Surgery. 2021; 169: 1026-1031
        • Tseng J.F.
        • Raut C.P.
        • Lee J.E.
        • Pisters P.W.T.
        • et al.
        Pancreaticoduodenectomy with vascular resection: Margin status and survival duration.
        J Gastrointest Surg. 2004; 8: 935-950
        • Verbeke C.S.
        Resection margins in pancreatic cancer.
        Surg Clin North Am. 2013; 93: 647-662
        • Tsai S.
        • Christians K.K.
        • George B.
        • et al.
        A phase II clinical trial of molecular profiled neoadjuvant therapy for localized pancreatic ductal adenocarcinoma.
        Ann Surg. 2018; 268: 610-619
        • Barnes C.A.
        • Aldakkak M.
        • Christians K.K.
        • et al.
        Radiographic patterns of first disease recurrence after neoadjuvant therapy and surgery for patients with resectable and borderline resectable pancreatic cancer.
        Surgery. 2020; 168: 440-447
        • Chatzizacharias N.A.
        • Tsai S.
        • Griffin M.
        • et al.
        Locally advanced pancreas cancer: Staging and goals of therapy.
        Surgery. 2018; 163: 1053-1062
        • Ferrone C.R.
        • Marchegiani G.
        • Hong T.S.
        • et al.
        Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer.
        Ann Surg. 2015; 261: 12-17
        • Wittmann D.
        • Hall W.A.
        • Christians K.K.
        • et al.
        Impact of neoadjuvant chemoradiation on pathologic response in patients with localized pancreatic cancer.
        Front Oncol. 2020; 10: 460
        • Tsai S.
        • George B.
        • Wittmann D.
        • et al.
        Importance of normalization of CA19-9 levels following neoadjuvant therapy in patients with localized pancreatic cancer.
        Ann Surg. 2020; 271: 740-747
        • Chavez M.I.
        • Tsai S.
        • Clarke C.N.
        • et al.
        Distal splenorenal and mesocaval shunting at the time of pancreatectomy.
        Surgery. 2019; 165: 298-306
        • Christians K.K.
        • Riggle K.
        • Keim R.
        • et al.
        Distal splenorenal and temporary mesocaval shunting at the time of pancreatectomy for cancer: Initial experience from the Medical College of Wisconsin.
        Surgery. 2013; 154: 123-131