Role of surgery in pancreatic cancer

Abstract

Treatment of pancreatic cancer is multimodal and surgery is an essential part, mandatory for curative potential. Also chemotherapy is essential, and serious postoperative complications or rapid disease progression may preclude completion of multimodal treatment. The sequence of treatment interventions has therefore become an important concern, and numerous ongoing randomized controlled trials compare clinical outcome after upfront surgery and neoadjuvant treatment with subsequent resection. In previous years, borderline resectable and locally advanced pancreatic cancer was most often considered unresectable. More effective chemotherapy together with the latest improvements in surgical expertise has resulted in extended operations, pushing the borders of resectability. Multivisceral resections with or without resection of major mesenteric vessels are now performed in numerous patients, resulting in better outcome, recorded as overall survival and/or patient reported outcome. But postoperative morbidity increases concurrently, and clinical benefit must be carefully evaluated against risk of potential harm, associated with new comprehensive multimodal treatment sequences. Even though cost/utility analyses are deficient, extended surgery has resulted in significantly longer and better life for many patients with no other treatment alternative. Improved selection of patients to surgery and/or chemotherapy will in the near future be possible, based on better tumor biology insight. Clinically available biomarkers enabling personalized treatment are forthcoming, but these options are still limited. The importance of surgical resection for each patient’s prognosis is presently increasing, justifying sustained expansion of the surgical treatment modality.

Omics Approaches in Pancreatic Adenocarcinoma

“…Unfortunately, PDAC continues to have the lowest five-year overall survival rate—still standing at 9% [2,3]. Based on this daunting scenario, PDAC is expected to become the second leading cause of cancer deaths by 2030 [4,5], partly due to less than 20% of patients being considered as resectable at time of diagnosis, with more than half of all patients suffering distant metastases at the moment of diagnosis [6,7]. There is a clear lack of prognostic and predictive biomarkers in PDAC.…”

Pancreatic Ductal Adenocarcinoma (PDAC) Organoids: The Shining Light at the End of the Tunnel for Drug Response Prediction and Personalized Medicine

“…Indeed, most of the patients are diagnosed at an advanced stage when metastases have already disseminated and consequently less than 20% of the patients are benefiting from tumor resection. Of note, despite providing a significant gain of 5-year survival, the surgical procedure still remains a challenging operation with high operative and postoperative risks [ 25 , 26 ]. In addition, a post-operation PDAC recurrence is observed in up to 80% of the cases [ 27 , 28 , 29 ].…”

Long term oncological outcome of laparoscopic techniques in pancreatic cancer

“…Accordingly, comparison of lymph node count in the specimens from different centers is associated with significant uncertainty, thus also comparison of oncological outcome of surgical methods, based on lymph node count. Also the rate of R0 resections is an unsafe oncological quality indicator, first because of various R0 definitions[14,15], second because neoadjuvant chemotherapy is used increasingly and R0 status has not been clearly defined in this situation. Due to spot wise death of tumor tissue during chemotherapy in PDAC, the R0 concept must be redefined.…”