Pancreatic%20cancer Treatment
Surgical Intervention
- Surgical resection is the definitive treatment of pancreatic cancer with a goal of achieving negative (R0) margins of resection
- Upfront surgery is the standard of care for resectable tumors
- Must be performed 4-8 weeks after neoadjuvant therapy
- Resection after >8 weeks following neoadjuvant therapy may be difficult due to radiation-induced fibrosis
- Decisions regarding resectability status should involve multidisciplinary consultation
Resectability Status Criteria
Locally and Clearly Resectable Tumors
- Distant metastases absent
- Evidence of superior mesenteric vein (SMV) or portal vein (PV) invasion absent on radiographic exam or ≤180 degrees encasement without vein distortion
- Surrounding structures of the celiac axis, common hepatic artery (CHA), and superior mesenteric artery (SMA) clear
Borderline Resectable Tumors
- Distant metastases absent
- Head/uncinate process: CHA encasement without extension to celiac axis or hepatic artery bifurcation allowing for complete resection and reconstruction; ≤180 degrees contact with SMA
- Body/tail: ≤180 degrees contact with the celiac axis or >180 degrees contact with celiac axis without involvement of the aorta and with intact and uninvolved gastroduodenal artery
- >180 degrees contact of tumor with SMV/PV or ≤180 degrees contact with SMV or PV venous involvement with distortion or narrowing, or venous occlusion with patent proximal and distal vessel allowing venous reconstruction
- Solid tumor contact with the inferior vena cava (IVC)
Locally Advanced Tumors
- Head/uncinate process: Distant metastases present; >180 degrees SMA encasement or celiac axis abutment; unreconstructable SMV/PV occlusion
- Body/tail: Distant metastases present; >180 degrees SMA or celiac axis encasement; unreconstructable SMV/PV occlusion; tumor contact with the celiac axis and aortic involvement
- All: Metastases to lymph node beyond the field of resection
Surgical Procedures
Pancreatoduodenectomy (Whipple Technique)
- Procedure of choice for pancreatic head and uncinate tumors
- Preserves the distal stomach and pylorus
- Further studies are suggested to prove the benefit of pylorus-preserving pancreatoduodenectomy as an alternative to the classic pancreatoduodenectomy
- Extended lymphadenectomy does not increase overall survival of patients undergoing Whipple technique
Distal Pancreatectomy with En-bloc Splenectomy
- Procedure of choice for pancreatic body and tail tumors
- Reports have shown a tumor clearance of 72-91% after distal pancreatectomy, with good long-term survival rates comparable to that of total resection for localized tumors
- Minimally invasive distal pancreatectomy (MIDP) may be considered for benign and low-grade malignant tumors
- Shown to have equivalent complication rates compared with open distal pancreatectomy and is associated with shorter hospital stay and reduced blood loss
Total Pancreatectomy
- The only curative treatment option for pancreatic cancer patients with stage I/II disease
- Indicated for multifocal tumors and tumors with borders that cannot be delineated with other techniques
- Involves removal of the entire pancreas, part of the small intestine, portion of the stomach, common bile duct, gall bladder, spleen and nearby lymph nodes
- Not recommended for patients ≥75 yr due to possible comorbidities