Resección vascular mayor por adenocarcinoma pancreático ductal: reporte del primer caso registrado en Paraguay / Major vascular resection for pancreatic ductal adenocarcinoma: case report, of first case reported in Paraguay

El adenocarcinoma pancreático ductal (APD) es la cuarta causa de muerte por cáncer y se proyecta que para el 2030 ocupe el segundo lugar. El pronóstico es sombrío, siendo la sobrevida menor a 9% en 5 años. Se consideró durante mucho tiempo a la resección quirúrgica como el único tratamiento curativo, sin embargo, sólo el 15 a 20% de los pacientes pueden ser beneficiados con la misma. La clasificación pre terapéutica más utilizada es la del National Comprehensive Cáncer Network (NCCN), basada en la relación del tumor con estructuras vasculares, clasificándolos en tumores "resecables", de resección límite "Borderlines" y "localmente avanzados". Se presenta el primer caso registrado en Paraguay de APD con infiltración de la Vena Mesentérica Superior (VMS) tratado con duodenopancreatectomía cefálica (DPC) asociada a resección vascular mayor.

Pancreatic ductal adenocarcinoma (PDA) is the fourth leading cause of cancer death and is projected to rank second by 2030. The prognosis is bleak, with survival being less than 9% in 5 years. For a long time, surgical resection was considered the only curative treatment, however, only 15 to 20% of patients can benefit from it. The most widely used pre-therapeutic classification is that of the National Comprehensive Cancer Network (NCCN), based on the relationship of the tumor with vascular structures, classifying them into "resectable", "borderline" and "locally advanced" tumors. We present the first registered case in Paraguay of PDA with infiltration of the Superior Mesenteric Vein (SMV) treated with cephalic duodenopancreatectomy (CPD) associated with major vascular resection.

Neoadjuvant Treatment of Borderline Resectable Pancreatic Cancer / 肿瘤防治研究

Borderline resectable pancreatic ductal adenocarcinoma accounts for approximately 20% of newly diagnosed pancreatic cancer patients. This type of adenocarcinoma is between resectable and unresectable. It has a high degree of heterogeneity and features in anatomy, biology, and physical condition. The biological characteristics of invasiveness determine that, rather than direct surgery, neoadjuvant therapy should be primarily given to patients to achieve R0 resection and avoid early postoperative recurrence. However, this treatment model is still controversial. According to the latest research on this topic, the full text summarizes the definition of BR-PDAC, resectable evaluation, neoadjuvant treatment selection and evaluation, surgical results after neoadjuvant therapy, and the efficacy of adjuvant therapy after neoadjuvant therapy.

Neoadjuvant therapy for pancreatic cancer / 中华消化外科杂志

Pancreatic cancer has a extremely high malignancy,and simple surgical resection can not significantly improve the long-term survival rate of patients.Neoadjuvant therapy is the preoperative chemotherapy or combined chemo radiotherapy,which is used for downstaging tumors,eliminating subclinical metastases,transforming unresectable into resectable tumors,and improving the R0 resection rate of pancreatic cancer,thus ultimately improving the efficacy of pancreatic cancer.At present,neoadjuvant therapy has gradually become the mainstream treatment for locally advanced and borderline resectable pancreatic cancer.New adjuvant therapy for resectable pancreatic cancer has been supported by some high-quality clinical research data,which will become a hot topic in clinical research.The author believes that there will be more clinical research data to help individualized neoadjuvant treatment selection,accurate efficacy evaluation and prognosis judgement,and ultimately improve the efficacy of patients with pancreatic cancer.

Clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein pathway for resectable pancreatic cancer / 中华消化外科杂志

Objective To investigate clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein (IMV) pathway for resectable pancreatic cancer with superior mesenteric vein (SMV) and / or anterior wall of portal vein (PV) involvements.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 38 resectable pancreatic cancer patients who underwent pancreaticoduodenectomy with venous resection via IMV pathway in the West China Hospital of Sichuan University between January 2013 and January 2017 were collected.The tumors of 25 patients were BR-PV type (simplex SMV and / or PV involvements),and tumors of 13 patients were BR-A type (SMV,celiac trunk and / or hcpatic artcry involvements).The pancreaticoduodenectomy via IMV pathway was the same as traditional surgery in organs resection and lymph node dissection,the difference was cutting off the pancreas at a junction between IMV and splenic vein when using IMV pathway.Observation indicators:(1) intraoperative and postoperative situations;(2) results of postoperative pathological examination;(3) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to January 2018.Measurement data with skewed distribution were described as M (range).The survival curve was drawn by the Kaplan-Meir method,and Log-rank test was used for survival analysis.Results (1)Intraoperative and postoperative situations:38 patients underwent intraoperative segmental resection of PV and / or SMV,including 30 with end-to-end anastomosis in situ and 8 with artificial vessel interposition anastomosis.Two of 38 patients were intraoperatively combined with common hepatic artery resection and end-to-end anastomosis in situ.There was no intraoperative celiac trunk resection.The operation time and volume of intraoperative blood loss of 38 patients were respectively 320 minutes (range,280-520 minutes) and 530 mL (range,420-650 mL).The incidence of total complications (Clavien-Dindo Ⅲ and above) of 38 patients was 18.4％ (7/38),and some patients were combined with multiple complications,including 6 with pulmonary infection,4 with pancreatic fistula (B and C grade),4 with intra-abdominal infection,3 with delayed gastric emptying,2 with postoperative bleeding and 2 with venous thrombosis.Five patients were cured by postoperative symptomatic treatment,and 2 with postoperative bleeding died of worsened condition after reoperation.The mortality at 90 days postoperatively and duration of hospital stay were respectively 5.3％(2/38) and 12 days (range,9-52 days).(2) Results of postoperative pathological examination:the R0 resection rate of 38 patients was 81.6％ (31/38).The R0 resection rate of 25 patients in BR-PV type was 92.0％ (23/25),and resection margin of pancreatic leading edge ＜ 1 mm was in 2 patients without R0 resection;R0 resection rate of 13 patients in BR-A type was 8/13,and resection margin of pancreatic leading edge ＜ 1 mm was in 2 patients and resection margin of SMV ＜ 1 mm was in 4 patients (1 margined with resection margin of multiple sites ＜ 1 mm) of patients without R0 resection.The resection margins of pancreatic trailing edge,venous cut edge and pancreatic cut edge in patients with BR-PV type and BR-A type were more than and equal to 1mm.The venous infiltration rate in patients with BR-PV type and BR-A type was respectively 100.0％ (25/25) and 9/13.(3) Follow-up and survival situations:38 patients were followed up for 6-40 months,with a median time of 15 months,and survival time was 18 months (range,6-40 months).The survival time and 1-,2-and 3-year cumulative survival rates were respectively 23 months (range,8-40 months),89.5％,33.1％,22.1％ in 25 patients with BR-PV type and 16 months (range,6-25 months),83.9％,16.8％,0 in 13 patients with BR-A type.The tumor-free survival time and 1-and 2-year cumulative tumor-free survival rates were respectively 15 months (range,5-30 months),63.0％,7.5％ in patients with BR-PV type and 9 months (range,4-18 months),11.5％,0 in patients with BR-A type.Conclusion For resectable pancreatic cancer with SMV and / or anterior wall of PV involvements,pancreaticoduodenectomy combined with venous resection via IMV pathway could avoid injury of SMV and / or PV,and increase negative rates of venous and pancreatic resection margins.

Role of Neoadjuvant Therapy for Borderline Resectable or Locally Advanced Pancreatic Cancer / 대한췌담도학회지

Surgical resection offers the only chance of cure for nonmetastatic exocrine pancreatic cancer. However, only 15 to 20 percent of patients have potentially resectable disease at diagnosis; approximately 40 percent have distant metastases, and another 30 to 40 percent have locally advanced unresectable tumors. Typically, patients with locally advanced unresectable pancreatic cancer have tumor invasion into adjacent critical structures, particularly the celiac and superior mesenteric arteries. The optimal management of these patients is controversial, and there is no internationally embraced standard approach. Therapeutic options include chemoradiotherapy or chemotherapy alone. While it is reasonable to restage and reevaluate the potential for resectability after neoadjuvant therapy, the frequency of a complete resection and long-term survival is low for patients who initially have categorically unresectable tumors. Others have disease that is categorized as "borderline resectable." While these patients are potentially resectable, the high likelihood of an incomplete resection has prompted interest in strategies to "downstage" the tumor or to increase the likelihood of a margin-negative resection prior to surgical exploration using neoadjuvant therapy. The rationale for neoadjuvant therapy is as follows. First, it is to improve the selection of patients for whom resection will not offer a survival benefit (i.e., those who rapidly progress to metastatic disease during preoperative therapy). Second, it is to increase rates of margin-negative resections, which is the major goal of surgery. Third, it is to start an early treatment of micrometastatic disease. Initial attempt at downstaging with chemotherapy, chemoradiotherapy, or a combination followed by restaging and surgical exploration in responders rather than upfront surgery is suggested.

Management of Borderline Resectable Pancreatic Cancer and Local Treatment of Locally Advanced Pancreatic Cancer / 대한췌담도학회지

With the advances in the imaging techniques, it is now possible to more accurately diagnose and stage pancreatic cancer. However, there is no uniform definition of "borderline resectable pancreatic cancer (BRPC)" and consensus on this terminology has not been reached yet. Although there has been much progress in the therapeutic strategies for pancreatic cancer, the optimal treatment scheme for BRPC is still under debate. In order to overcome these problems, prospective studies using multidisciplinary approaches are warranted. This article is intended to review the currently available definitions and management of BRPC. Promising novel ablative methods that are used as local treatments for locally advanced pancreatic cancer are also introduced. In the near future, these ablative methods might prove to be invaluable for those with BRPC.

Updates on neoadjuvant therapy in borderline resectable pancreatic cancer / 中华肝胆外科杂志

Borderline resectable pancreatic cancer (BRPC),characterized by low resectability rate and high postoperative recurrence rate,is a special kind of pancreatic cancer between resectable type and nonresectable one.Currently,the efficacy of neoadjuvant therapy for BRPC has become a hot topic in the field of pancreatic cancer.Although neoadjuvant therapy plays a critical role in obviously improving the R0 resectability rate and survival status of BRPC patients,the normalized therapeutic regimen has not been established.In this article,we overviewed the recent progress on the neoadjuvant therapy in treating BRPC.