Commentary: Surgery for locally advanced pancreatic cancer after neoadjuvant therapy

Abstract

The relationship of tumors in the head, neck, and body of the pancreas to adjacent visceral vessels has become increasing complex with respect to staging and treatment, attributable to the improved responses observed with current neoadjuvant therapies. In this issue of Surgery, internationally known experts in the field from the United States and Europe comment on the technical aspects of arterial dissection (at the time of pancreatectomy), with special reference to the plane of dissection between the autonomic nerve and the adventitia of the artery. 1 Diener M.K. Mihaljevic A.L. Strobel O. et al. Periarterial divestment in pancreatic cancer surgery. Surgery. 2021; 169: 1019-1025 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar ,2 Habib J.R. Kinny-Köster B. van Oosten F. et al. Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: Surgical planning with the “halo sign” and the “string sign.”. Surgery. 2021; 169: 1026-1031 Abstract Full Text Full Text PDF Scopus (6) Google Scholar For decades we have emphasized removal of the perineural and soft tissue to the right of the superior mesenteric artery (SMA) at the time of pancreaticoduodenectomy, and Tseng et al 3 Tseng J.F. Raut C.P. Lee J.E. Pisters P.W.T. et al. Pancreaticoduodenectomy with vascular resection: Margin status and survival duration. J Gastrointest Surg. 2004; 8: 935-950 Crossref PubMed Scopus (450) Google Scholar and Verbeke 4 Verbeke C.S. Resection margins in pancreatic cancer. Surg Clin North Am. 2013; 93: 647-662 Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar have elegantly demonstrated how tumor cells can be left behind, often at a considerable distance from the boundaries of the gross tumor. A combination of optimal surgical technique (to include resection of the autonomic nerve adjacent to the visceral arteries) and preoperative radiation therapy (as part of the neoadjuvant treatment program) will minimize local recurrence. 5 Tsai S. Christians K.K. George B. et al. A phase II clinical trial of molecular profiled neoadjuvant therapy for localized pancreatic ductal adenocarcinoma. Ann Surg. 2018; 268: 610-619 Crossref PubMed Scopus (31) Google Scholar It is important to note that local recurrence will become radiographically and clinically evident only if the patient survives the risk of early distant recurrence. 6 Barnes C.A. Aldakkak M. Christians K.K. et al. Radiographic patterns of first disease recurrence after neoadjuvant therapy and surgery for patients with resectable and borderline resectable pancreatic cancer. Surgery. 2020; 168: 440-447 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Our approach to the visceral arteries as well as to the superior mesenteric vein-portal vein (SMV-PV) at the time of pancreatectomy for locally advanced pancreatic cancer has been recently published and emphasizes the importance of both treatment sequencing and the technical aspects of surgery based on tumor location. 7 Chatzizacharias N.A. Tsai S. Griffin M. et al. Locally advanced pancreas cancer: Staging and goals of therapy. Surgery. 2018; 163: 1053-1062 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar