Conversion Surgery for Advanced Pancreatic Cancer

Abstract

While primarily unresectable locally advanced pancreatic cancer (LAPC) used to be an indication for palliative therapy, a strategy of neoadjuvant therapy (NAT) and conversion surgery is being increasingly used after more effective chemotherapy regimens have become available for pancreatic ductal adenocarcinoma. While high-level evidence from prospective studies is still sparse, several large retrospective studies have recently reported their experience with NAT and conversion surgery for LAPC. This review aims to provide a current overview about different NAT regimens, conversion rates, survival outcomes and determinants of post-resection outcomes, as well as surgical strategies in the context of conversion surgery after NAT. FOLFIRINOX is the predominant regimen used and associated with the highest reported conversion rates. Conversion rates considerably vary between less than 5% and more than half of the study population with heterogeneous long-term outcomes, owing to a lack of intention-to-treat analyses in most studies and a high heterogeneity in resectability criteria, treatment strategies, and reporting among studies. Since radiological criteria of local resectability are no longer applicable after NAT, patients without progressive disease should undergo surgical exploration. Surgery after NAT has to be aimed at local radicality around the peripancreatic vessels and should be performed in expert centers. Future studies in this rapidly evolving field need to be prospective, analyze intention-to-treat populations, report stringent and objective inclusion criteria and criteria for resection. Innovative regimens for NAT in combination with a radical surgical approach hold high promise for patients with LAPC in the future.

Predictive model for the intraoperative unresectability of hilar cholangiocarcinoma: Reducing futile surgical exploration

“…A previous study revealed that the median waiting time for HCCA surgery was 74 days, which did not impact resectability, metastasis, tumor stage or survival [ 38 ]. Consistent with this conclusion, we suggest evaluating borderline HCCA patients receiving preoperative neoadjuvant therapy, similar to the evaluation process for pancreatic cancer patients [ 39 ]. These noninvasive methods could downstage and evaluate the sensitivity of chemotherapy, which assists in evaluating surgical necessity and reducing the number of senseless exploration procedures.…”

A case of pathological complete response with liposomal irinotecan + 5-FU/LV for unresectable locally advanced pancreatic cancer

“…Instead, local resectability can only be assessed by surgical exploration, with frozen section biopsies. If the frozen biopsy reveals a persistent true invasion of a major artery, surgical resection can be abandoned, or the decision for an arterial resection must be made [22]. In our case, however, a preoperative CT revealed that the tumor had shrunk to 18 × 7 mm in diameter with encasement of the CHA, so the findings of UR-LA pancreatic cancer remained, and intraoperative frozen section pathology findings confirmed tumorfree margins.…”

Chirurgie periampullärer Pankreaskarzinome

“…Für Patienten mit resektablem und Borderline-resektablem Pankreaskarzinom kann auf Basis der aktuellen Datenlage eine primäre chirurgische Therapie empfohlen werden, wobei neoadjuvante Konzepte derzeit in randomisiert-kontrollierten Studien überprüft werden [ 17 ]. Lokal fortgeschrittene Pankreaskarzinome mit Infiltration oder Ummauerung der Arteria mesenterica superior oder des Truncus coeliacus sind per definitionem nicht resektabel und sollten daher mit einer neoadjuvanten Chemotherapie behandelt werden [ 18 ]. In der Praxis erfolgen die Beurteilung der Resektabilität und die Behandlungsallokation jedoch auch und gerade in interdisziplinären Tumorboards häufig auf der Grundlage persönlicher Erfahrungen und anhand nichtstandardisierter Parameter, sodass hier eine große Behandlungsheterogenität zu verzeichnen ist [ 19 ].…”