Extended distal pancreatectomy with thoracic wall resection after neoadjuvant FOLFIRINOX: Is there a limit of resection for pancreatic cancer after downstaging?

Abstract

Indications and outcomes of extended pancreatectomies have been recently appraised by the International Study Group for Pancreatic Surgery. However, no definitive conclusions have been drawn, particularly in the setting of neoadjuvant treatments. We present here a case of 53-year-old man diagnosed with a bulky adenocarcinoma of the tail of the pancreas and infiltrating the adjacent organs and the thoracic wall. The patient was sent to neoadjuvant chemotherapy and he underwent 12 cycles of FOLFIRINOX. Since a significant radiological response was observed after chemotherapy, the patient was scheduled for extended distal pancreatectomy with en bloc resection of the thoracic wall, in order to achieve a radical resection. The surgery is herein described with all technical details. The patient was discharged after an uneventful early post-operative course and subsequently readmitted for a late grade B post-operative pancreatic fistula, which was ultimately treated successfully. Pathology showed complete response. When performed in centers with ample experience in pancreatic surgery, extended pancreatic resections represent a viable curative option with acceptable surgical outcomes. In this setting, challenging tailored resections should be considered to achieve negative margins, particularly following maximized effective downstaging strategies.

Successful En Bloc Resection of Locally Advanced Pancreatic Tail Cancer with Colonic Perforation Following Neoadjuvant Chemotherapy: A Case Report

“…Successful extended DP with a partial resection of the thoracic wall after downstaging by NAC using FOLFIRINOX was first reported in 2020 by Giuliani et al [ 12 ]. These authors stressed the importance of administering neoadjuvant strategies such as chemotherapy and radiotherapy with the aim of downstaging or reducing the tumor size in patients with locally advanced or borderline resectable pancreatic cancer [ 12 ].…”

“…Successful extended DP with a partial resection of the thoracic wall after downstaging by NAC using FOLFIRINOX was first reported in 2020 by Giuliani et al [ 12 ]. These authors stressed the importance of administering neoadjuvant strategies such as chemotherapy and radiotherapy with the aim of downstaging or reducing the tumor size in patients with locally advanced or borderline resectable pancreatic cancer [ 12 ]. Additionally, it has been shown that neoadjuvant therapy such as chemo-therapy or chemoradiotherapy facilitates attainment of negative margins after resection of originally borderline or locally advanced pancreatic cancer [ 13 ].…”