Radical Procedures in Patients with Pancreatic Cancer – Impact on Prolongation and Quality of Life

Czech version

Authors: M. Ryska
Authors‘ workplace: Chirurgická klinika 2. LF UK a ÚVN Praha
Published in: Rozhl. Chir., 2010, roč. 89, č. 12, s. 725-730.
Category: Monothematic special - Original

Overview

Introduction:
In conjunction with adjuvant chemotherapy, radical resections are the only treatment modality, which significantly prolongs survival in pancreatic cancer (CaP) patients. The author aims to define current standards of radical pancreatic resections in CaP patients and to assess benefits of the surgical procedure based on literature data, as well as to evaluate current options for objective assessment of the quality of life in these patients.

Methods:
Employing Pubmed and Ebscohost databases, the author compares radical pancreatic resections depending on the tumor location, performed in conjunction with standard lymphadenectomy in patients with CaP, with the extended version of the resection procedure. The radical procedure is then put into relationship with potential prolongation of survival times, with early mortality incidence rates and with rates of perioperative complications. Based on literature data, the author evaluates current options for objective assessment of the quality of life in these patients.

Outcomes:
Radical resection with lymphadenectomy in N1-2 diseases followed by adjuvant chemotherapy is currently considered a standard treatment procedure, the only one which significantly prolongs survival in patients with CaP, with the disease stage T1-3, N0-1M0. Angioinvasion into the portomesenteric segment is not a contraindication for the resection procedure. In cases where R0 resection is achieved, the outcomes are similar to those in subjects without vascular segment resections.

Views on arterial resections – a. hepatica, truncus coeliacus, a. mesenterica sup. are not uniform and, to date, resections of tumor-infiltrated arteries have not been shown to result in life prolongation. Angioinvasion into arteries is considered a sign of the disease stage and the need for extended procedures is associated with increased complication rates. The quality of life following resection procedures is not commonly assessed and its improvement is usually expected, rather than objectively assessed. At the present time, no questionnaire on the quality of life, which would specifically address CaP patients, is being used on a routine basis.

Discussion and Conclusions:
Radical resection R0 and administration of adjuvant chemotherapy is the only current treatment modality in patients with ductal pancreatic adenocarcinoma, which results in significant life prolongation with 7-25% five-year survival rates (median of 15–18.5 months). The tumor’s biological characteristics and the fact that the real disease staging is difficult to establish, are the reasons for early relapses after so called R0 resections. Resections of the portomesenteric segment in cases with adherence or penetration of the CaP into the vascular wall is indicated as a part of the radical PDE and do not result in shorter survival times.

Extended radical procedures with arterial resections (a. hepatica, truncus coeliacus, a. mesenterica sup.) do not result in prolonged survival times even in cases where the procedures were assessed as R0 procedures, and cannot be thought of as standard procedures. By using invasive resection procedures, the number of resecable patients would increase, however, the prize of this treatment decision may need to paid off by higher complication rates, compared to those in standard procedures, as well as by lower postoperative quality of life of the patients, while achieving comparable survival time outcomes.

Key words:
pancreatic cancer – resection procedure – quality of life

Sources

1. Alexakis, N., Halloran, C., Raraty, M., et al. Current standard of surgery for pancreatic cancer. BJS, 2004, 91: 1410–1427.

2. Koliopanos, A., Avgerinos, C., Farfaras, A., et al. Radical resection of pancreatic cancer. Hepatobiliary Pancreat Dis. Int., 2008; 7: 11–18.

3. Glanemann, M., Shi, B., Liang, F., et al. Surgical strategies for treatment of malignit pancreatic tumors: extended, standard or local surgery? World J. Surg. Oncol., 2008; 4–6: 123.

4. Allema, J. H., Reinders, M. E., van Gulik, T. M., et al. Prognostic factors for survival after pancreaticoduodenectomy for patients with carcinoma of the pancreatic head region. Cancer, 75, 1995: 2069–2076.

5. Patel, A. G., Toyama, M. K., Kusske, A. M., et al. Pylorus – preserving Whipple resection for pancreatic cancer. Is it better? Arch. Surg., 130, 1995: 838–843.

6. Weitz, J., Rahbari, N., Koch, M., Büchler, M. W. The „artery first“ approach for resection of pancreatic head cancer. J. Am. Coll. Surg., 210; 2010: 1–4.

7. Büchler, M. W., Wagner, M., Schmied, B. M., et al. Changes in Morbidity After Pancreatic Resection. Toward the End of Completion Pancreatectomy. Arch. Surg., 2003; 138: 1210–1314.

8. Friess, H., Kleeff, J., Kulli, C., et al. The impact of different types of surgery in pancreatic cancer. Eur. J. Surg. Oncol., 25, 1999: 124–131.

9. Ihse, I., Andrén-Sandberg, A. Surgical treatment: total pancreatectomy. In: Beger, H., Warshaw, A. L., Büchler, M. W., et al. Pancreas. Blackwell Science, London, 1998: 1047–1054.

10. Tsunoda, T., Ura, K., Eto, T., et al. UICC and Japanese stage classifications for carcinoma of the pancreas. Int. J. Pancreatol., 8, 1991: 205–214.

11. Reddy, S. K., Tyler, D. S., Pappas, T. N., et al. Extended resection for pancreatic adenocarcinoma. The Oncologist, 2007; 12: 654–663.

12. Chen, B., Hu, S., Wang, L., et al. Extended pancreatectomy with en bloc resection of the celiac axis for locally advanced cancer of pancreatic body and tail. , 2008; 55: 2252–2255.

13. Denecke, T., Andreou, A., Podrabsky, P., et al. Distal Pancreatectomy With En Bloc Resection of the Celiac Trunk for Extended Pancreatic Tumor Disease: An Interdisciplinary Approach. Cardiovasc. Intervent. Radiol., 2010 Oct 9. [Epub ahead of print]

14. Fortner, J. G., Kim, D. K., Cubilla, A., et al. Regional resection of cancer of the pancreas: a new surgical approach. Surgery, 1977; 73: 307–320.

15. Michalski, C. W., Kleeff, J., Wente, M. N., et al. Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer. Br. J. Surg., 2007; 94: 265–273.

16. Schniewind, B., Bestmann, B., Henne-Bruns, D., et al. Quality of life after pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head. Br. J. Surg., 2006; 93: 1099–1107.

17. Nikfarjam, M., Sehmbey, M., Kimchi, E. T., et al. Additional organ resection combined with pancreaticoduodenectomy does not increase postoperative morbidity and mortality. J. Gastrointest. Surg., 2009; 13: 915–921.

18. Schafer, M., Mullhaupt, B., Clavien, P. A. Evidence-Based pancreatic head resection for pancreatic cancer and chronic pankreatitis. Ann. Surg., 2002; 236: 137–148.

19. Scheingraber, S., Scheingraber, T., Brauckhoff, M., et al. Comparison between a general and a disease-specific health-related quality-of-life questionnaire in patients after pancreatic Sumery. J. Hepatobiliary Pancreat. Surg., 2005; 12: 290–297.

20. Pezzilli, R., Fantini, L., Morselli-Labate, A. M. Pancreatectomy for Pancreatic Disease and Quality of Life. J. Pancreas, 2007; 8:118–131.

21. Beger, H. G., Rau, B., Gansauge, F., et al. Treatment of pancreatic cancer: challenge of the facts. World J. Surg., 2003, 27: 1075–1084.

22. Siriwardana, H. P., Siriwardana, A. K. Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer. Br. J. Surg., 2006; 93: 662–673.