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Current State of Vascular Resections in Pancreatic Cancer Surgery.

Hackert T, Schneider L, Büchler MW - Gastroenterol Res Pract (2015)

Bottom Line: The only chance for long-term survival is radical surgical resection followed by adjuvant chemotherapy which can be performed in about 20% of all PDAC patients by the time of diagnosis.As pancreatic surgery has significantly changed during the past years, extended operations, including vascular resections, have become more frequently performed in specialized centres and the border of resectability has been pushed forward to achieve a potentially curative approach in the respective patients in combination with neoadjuvant and adjuvant treatment strategies.This overview summarizes the possibilities and evidence of vascular, namely, venous and arterial, resections in PDAC surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.

ABSTRACT
Pancreatic cancer (PDAC) is the fourth leading cause of cancer-related mortality in the Western world and, even in 2014, a therapeutic challenge. The only chance for long-term survival is radical surgical resection followed by adjuvant chemotherapy which can be performed in about 20% of all PDAC patients by the time of diagnosis. As pancreatic surgery has significantly changed during the past years, extended operations, including vascular resections, have become more frequently performed in specialized centres and the border of resectability has been pushed forward to achieve a potentially curative approach in the respective patients in combination with neoadjuvant and adjuvant treatment strategies. In contrast to adjuvant treatment which has to be regarded as a cornerstone to achieve long-term survival after resection, neoadjuvant treatment strategies for locally advanced findings are currently under debate. This overview summarizes the possibilities and evidence of vascular, namely, venous and arterial, resections in PDAC surgery.

No MeSH data available.


Related in: MedlinePlus

CT scan (coronary reconstruction) showing PDAC tumor infiltration of the portal vein confluence (white circle). Superior mesenteric vein (black arrow), portal vein (broken black arrow), and splenic vein (white arrow) without thrombosis, adequate diameter of the portal, and superior mesenteric vein to perform an end-to- end anastomosis.
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Related In: Results  -  Collection


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fig1: CT scan (coronary reconstruction) showing PDAC tumor infiltration of the portal vein confluence (white circle). Superior mesenteric vein (black arrow), portal vein (broken black arrow), and splenic vein (white arrow) without thrombosis, adequate diameter of the portal, and superior mesenteric vein to perform an end-to- end anastomosis.

Mentions: Situations in which vascular resections are required are often described as “borderline resectable” findings. In 2014, the International Study Group for Pancreatic Surgery (ISGPS) has published a consensus statement to standardize the definition of borderline resectability in accordance with the guidelines of the National Comprehensive Cancer Network (NCCN) as well as the definition of extended resections [11, 12]. Following these recommendations, preoperative evaluation of resectability should be based on a computed tomography (CT) scan with a pancreas-specific protocol, for example, a “hydropancreas” CT, as this offers best local resolution with regard to tumor extension and infiltration towards the vascular structures (Figure 1). Three grades of resectability can be defined for localized PDAC which are termed as “resectable,” “borderline resectable,” and “irresectable” [11]. While a resectable tumor has no vascular attachment (no distortion of the venous structures and clearly preserved fat planes towards the arteries), borderline resectability is defined as distortion/narrowing/occlusion of the mesentericoportal veins with a technical possibility of reconstruction on the proximal and distal margin of the veins. Furthermore, a semicircumferential abutment (≤180°) of the superior mesenteric artery (SMA) or an attachment at the hepatic artery without the celiac axis is regarded as a borderline resectable finding. Consequently, irresectability is defined as a more extended involvement of the SMA, the celiac axis, aorta or inferior vena cava. Furthermore, involvement of the mesentericoportal venous system can fulfill the criteria of irresectability if there is no technical possibility for reconstruction, for example, in case of tumor-associated portal cavernous transformation.


Current State of Vascular Resections in Pancreatic Cancer Surgery.

Hackert T, Schneider L, Büchler MW - Gastroenterol Res Pract (2015)

CT scan (coronary reconstruction) showing PDAC tumor infiltration of the portal vein confluence (white circle). Superior mesenteric vein (black arrow), portal vein (broken black arrow), and splenic vein (white arrow) without thrombosis, adequate diameter of the portal, and superior mesenteric vein to perform an end-to- end anastomosis.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4644845&req=5

fig1: CT scan (coronary reconstruction) showing PDAC tumor infiltration of the portal vein confluence (white circle). Superior mesenteric vein (black arrow), portal vein (broken black arrow), and splenic vein (white arrow) without thrombosis, adequate diameter of the portal, and superior mesenteric vein to perform an end-to- end anastomosis.
Mentions: Situations in which vascular resections are required are often described as “borderline resectable” findings. In 2014, the International Study Group for Pancreatic Surgery (ISGPS) has published a consensus statement to standardize the definition of borderline resectability in accordance with the guidelines of the National Comprehensive Cancer Network (NCCN) as well as the definition of extended resections [11, 12]. Following these recommendations, preoperative evaluation of resectability should be based on a computed tomography (CT) scan with a pancreas-specific protocol, for example, a “hydropancreas” CT, as this offers best local resolution with regard to tumor extension and infiltration towards the vascular structures (Figure 1). Three grades of resectability can be defined for localized PDAC which are termed as “resectable,” “borderline resectable,” and “irresectable” [11]. While a resectable tumor has no vascular attachment (no distortion of the venous structures and clearly preserved fat planes towards the arteries), borderline resectability is defined as distortion/narrowing/occlusion of the mesentericoportal veins with a technical possibility of reconstruction on the proximal and distal margin of the veins. Furthermore, a semicircumferential abutment (≤180°) of the superior mesenteric artery (SMA) or an attachment at the hepatic artery without the celiac axis is regarded as a borderline resectable finding. Consequently, irresectability is defined as a more extended involvement of the SMA, the celiac axis, aorta or inferior vena cava. Furthermore, involvement of the mesentericoportal venous system can fulfill the criteria of irresectability if there is no technical possibility for reconstruction, for example, in case of tumor-associated portal cavernous transformation.

Bottom Line: The only chance for long-term survival is radical surgical resection followed by adjuvant chemotherapy which can be performed in about 20% of all PDAC patients by the time of diagnosis.As pancreatic surgery has significantly changed during the past years, extended operations, including vascular resections, have become more frequently performed in specialized centres and the border of resectability has been pushed forward to achieve a potentially curative approach in the respective patients in combination with neoadjuvant and adjuvant treatment strategies.This overview summarizes the possibilities and evidence of vascular, namely, venous and arterial, resections in PDAC surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.

ABSTRACT
Pancreatic cancer (PDAC) is the fourth leading cause of cancer-related mortality in the Western world and, even in 2014, a therapeutic challenge. The only chance for long-term survival is radical surgical resection followed by adjuvant chemotherapy which can be performed in about 20% of all PDAC patients by the time of diagnosis. As pancreatic surgery has significantly changed during the past years, extended operations, including vascular resections, have become more frequently performed in specialized centres and the border of resectability has been pushed forward to achieve a potentially curative approach in the respective patients in combination with neoadjuvant and adjuvant treatment strategies. In contrast to adjuvant treatment which has to be regarded as a cornerstone to achieve long-term survival after resection, neoadjuvant treatment strategies for locally advanced findings are currently under debate. This overview summarizes the possibilities and evidence of vascular, namely, venous and arterial, resections in PDAC surgery.

No MeSH data available.


Related in: MedlinePlus