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Commentary on: Periarterial divestment in pancreatic cancer surgery

Published:December 15, 2020DOI:https://doi.org/10.1016/j.surg.2020.10.043
      The surgeon’s role and contribution to patients with nonmetastatic pancreatic cancer is to provide both a safe and an oncologically sound cancer operation to remove all locoregional disease and prevent local recurrence. Although a pancreatectomy is necessary for long-term survival, resection alone is insufficient. We have come to understand the realistic limitations of surgery for this particular malignancy via our experience with upfront resection, using standard techniques. This includes the proven critical importance of a negative margin operation that has been demonstrated clearly to affect survival outcomes and local recurrence rates. Furthermore, it is also evident that the majority of patients with localized disease harbor occult systemic metastases, regardless of initial radiologic clinical staging; these occult metastases negate the potential benefits of curative-intent resections. In addition, given the known complications associated with pancreatectomy, many patients are unable to complete or even initiate the well-established benefit of postoperative systemic adjuvant chemotherapy. Given these limitations, we have evolved our treatment paradigms to include risk stratification based on these factors, incorporating a multidisciplinary approach to improve outcomes for our patients. Specifically with anatomic concerns, we have created resectability criteria based on extrapancreatic extension and tumoral vascular involvement in an effort to identify those patients who would be at high risk of a positive margin with an upfront, standard, anatomic-plane based resection and not a true en bloc vascular resection. These criteria have resulted in the anatomic concepts of borderline resectable (BR) and locally advanced (LA), for better or worse and, most likely, the latter. During the past few years, we have also seen dramatic improvements in systemic therapeutics using combinatorial regimens such as FOLFIRINOX or gemcitabine/nab-paclitaxel as well as locoregional chemoradiation modalities for local control and margin enhancement. We have also become more comfortable with more extensive vascular resections (primarily venous) and substantially improved our perioperative care with the incorporation of strategies to mitigate complications. As a result of these advances, we have incorporated these innovative approaches into our current treatment paradigms and, for those with more anatomically advanced tumors (BR/LA), we currently consider neoadjuvant therapy (induction chemotherapy ± chemoradiation) before potential resection. Despite the majority of patients with BR/LA tumors undergoing such a preoperative strategy, there remains considerable debate about what to do after we have completed neoadjuvant therapy, specifically in the subset of patients with tumors that encase major arteries (hepatic, celiac, and/or superior mesenteric artery).
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