Surgical Management of Early-Stage Pancreatic Cancer
Surgical Management of Early-Stage Pancreatic Cancer
Background: Pancreatic cancer remains a difficult disease to treat. Diagnosis at an early stage may allow curative treatment with resection. In the past, the mortality associated with surgical treatment of pancreatic carcinoma was prohibitive but mortality associated with resection is now commensurate with all other major oncologic resections. Thus, the focus of surgical management has shifted to address several issues: the diagnosis and evaluation of patients with suspected pancreatic cancer, the role of preoperative endobiliary stenting, the role of laparoscopy, the extent of resection, the role of adjuvant and neoadjuvant treatment, and the role of specialized centers in treating the disease.
Methods: The current literature is reviewed to address these issues and help guide physicians who first encounter patients with suspected pancreatic cancer as well as surgeons who ultimately resect them. Practical evidence-based information to guide the decision-making process is provided.
Results: Surgical morbidity and mortality have achieved parity with other types of major oncologic resection, and a distinct survival advantage is possible when such therapy is applied early in the disease stage. Issues regarding the use of stents, extent of resection, and pre-vs post-operative chemoradiation therapy are becoming clearer as our collective experience broadens.
Conclusions: Surgical treatment of pancreatic cancer should be aggressively pursued given the clearly established survival advantage and relief of symptoms achieved when it is applied appropriately.
Pancreatic cancer is the fourth leading cause of cancer death in the United States. In 2003, an estimated 30,700 patients were diagnosed with pancreatic cancer, the majority of whom presented with locally advanced or metastatic disease that precludes potentially curative surgical therapy. Approximately 4,000 patients will have resectable disease at presentation, and these patients comprise a select group that can achieve a 20% to 40% 5-year survival depending on their age, size of tumor, grade, stage, and differentiation. In most recent large series of patients undergoing resection for pancreatic cancer, perioperative mortality is now less than 5% and median survival between 12 and 20 months. Five-year survival remains dismal, however, when all patients (including those with positive resection margins) are considered in the survival analysis. Despite these discouraging statistics, they remain in direct contrast to median survival of 4 to 8 months for patients who present with locally advanced disease and 3 to 5 months for patients who present with metastatic disease. Morbidity remains between 20% to 50%, but current focus of surgical management is not whether to undertake the resection but how to minimize morbidity and maximize potential survival benefit. A review of recent large series of patients undergoing pancreaticoduodenectomy for carcinoma is presented in Table 1 .
Current issues regarding the surgical management of pancreatic cancer can be separated into three categories: preoperative, intraoperative, and postoperative. Preoperative issues include how to best diagnose, evaluate, and palliate candidates for potential resection and where, and by whom, these resections should be undertaken. The use of neoadjuvant therapy is also becoming an important preoperative issue as promising data regarding its thoughtful application are now becoming available. Intraoperative issues include the appropriate use of laparoscopy and the extent of resection that should be undertaken to provide a reasonable hope of survival benefit or palliation when tempered with potential morbidity. Postoperative issues include the role of adjuvant therapy and how to best follow the patient undergoing resection for pancreatic cancer. These issues in the surgical management of pancreatic cancer are delineated in Table 2 and serve as an outline for the remainder of this manuscript.
Background: Pancreatic cancer remains a difficult disease to treat. Diagnosis at an early stage may allow curative treatment with resection. In the past, the mortality associated with surgical treatment of pancreatic carcinoma was prohibitive but mortality associated with resection is now commensurate with all other major oncologic resections. Thus, the focus of surgical management has shifted to address several issues: the diagnosis and evaluation of patients with suspected pancreatic cancer, the role of preoperative endobiliary stenting, the role of laparoscopy, the extent of resection, the role of adjuvant and neoadjuvant treatment, and the role of specialized centers in treating the disease.
Methods: The current literature is reviewed to address these issues and help guide physicians who first encounter patients with suspected pancreatic cancer as well as surgeons who ultimately resect them. Practical evidence-based information to guide the decision-making process is provided.
Results: Surgical morbidity and mortality have achieved parity with other types of major oncologic resection, and a distinct survival advantage is possible when such therapy is applied early in the disease stage. Issues regarding the use of stents, extent of resection, and pre-vs post-operative chemoradiation therapy are becoming clearer as our collective experience broadens.
Conclusions: Surgical treatment of pancreatic cancer should be aggressively pursued given the clearly established survival advantage and relief of symptoms achieved when it is applied appropriately.
Pancreatic cancer is the fourth leading cause of cancer death in the United States. In 2003, an estimated 30,700 patients were diagnosed with pancreatic cancer, the majority of whom presented with locally advanced or metastatic disease that precludes potentially curative surgical therapy. Approximately 4,000 patients will have resectable disease at presentation, and these patients comprise a select group that can achieve a 20% to 40% 5-year survival depending on their age, size of tumor, grade, stage, and differentiation. In most recent large series of patients undergoing resection for pancreatic cancer, perioperative mortality is now less than 5% and median survival between 12 and 20 months. Five-year survival remains dismal, however, when all patients (including those with positive resection margins) are considered in the survival analysis. Despite these discouraging statistics, they remain in direct contrast to median survival of 4 to 8 months for patients who present with locally advanced disease and 3 to 5 months for patients who present with metastatic disease. Morbidity remains between 20% to 50%, but current focus of surgical management is not whether to undertake the resection but how to minimize morbidity and maximize potential survival benefit. A review of recent large series of patients undergoing pancreaticoduodenectomy for carcinoma is presented in Table 1 .
Current issues regarding the surgical management of pancreatic cancer can be separated into three categories: preoperative, intraoperative, and postoperative. Preoperative issues include how to best diagnose, evaluate, and palliate candidates for potential resection and where, and by whom, these resections should be undertaken. The use of neoadjuvant therapy is also becoming an important preoperative issue as promising data regarding its thoughtful application are now becoming available. Intraoperative issues include the appropriate use of laparoscopy and the extent of resection that should be undertaken to provide a reasonable hope of survival benefit or palliation when tempered with potential morbidity. Postoperative issues include the role of adjuvant therapy and how to best follow the patient undergoing resection for pancreatic cancer. These issues in the surgical management of pancreatic cancer are delineated in Table 2 and serve as an outline for the remainder of this manuscript.