Ductal carcinoma of the pancreas. Rationales for total pancreatectomy

Pancreatic Cancer: 80 Years of Surgery-Percentage and Repetitions

Objective. The incidence of pancreatic cancer is estimated to be 48,960 in 2015 in the US and projected to become the second and third leading causes of cancer-related deaths by 2030. The mean costs in 2015 may be assumed to be $79,800 per patient and for each resection $164,100. Attempt is made to evaluate the results over the last 80 years, the number of survivors, and the overall survival percentage. Methods. Altogether 1230 papers have been found which deal with resections and reveal survival information. Only 621 of these report 5-year survivors. Reservation about surgery was first expressed in 1964 and five-year survival of nonresected survivors is well documented. Results. The survival percentage depends not only on the number of survivors but also on the subset from which it is calculated. Since the 1980s the papers have mainly reported the number of resections and survival as actuarial percentages, with or without the actual number of survivors being reported. The actuarial percentage is on average 2.75 higher. Detailed information on the original group (TN), number of resections, and actual number of survivors is reported in only 10.6% of the papers. Repetition occurs when the patients from a certain year are reported several times from the same institution or include survivors from many institutions or countries. Each 5-year survivor may be reported several times. Conclusion. Assuming a 10% resection rate and correcting for repetitions and the life table percentage the overall actual survival rate is hardly more than 0.3%.

Total pancreatectomy in six patients with intraductal papillary mucinous tumour of the pancreas: the treatment of choice

BACKGROUND

Intraductal papillary mucinous tumours (IPMT) were described as a distinct entity in 1982.The extent of surgical resection remains controversial.

METHODS

Six patients with a diffuse dilatation of the main pancreatic duct were treated with total pancreatectomy for cure of IPMT.

RESULTS

Histological examination showed one IPM adenoma, four IPM non-invasive carcinomas and one IPM invasive carcinoma. In all but one case multifocal extensive intraductal changes were found, affecting either most of the pancreas or the whole organ. All patients survived the operation and remain alive 5-56 months later. Post-pancreatectomy diabetes has been moderately well controlled.

DISCUSSION

IPMTs represent a subgroup of pancreatic neoplasms with a favourable prognosis, and the resection should aim at removing all dysplastic foci. In cases with diffuse dilatation of the main pancreatic duct, widespread tumour involvement of the duct system can be expected, so total pancreatectomy should be the operation of choice.

Villous adenoma of the main pancreatic duct: a clue to the pathogenesis of pancreatic malignancy

We describe the case of a 78 year old woman with a severely dysplastic villous adenoma of the duct of Wirsung presenting with abdominal pain, emesis, weight loss, and hyperamylasemia. Abdominal ultrasound, computed tomography, and endoscopic retrograde cholangiopancreatography suggested an intraductal lesion in the head of the pancreas with a dilated distal duct. The patient underwent uncomplicated pancreaticoduodenectomy and has done well. A review of the literature on benign and malignant neoplasms of the main pancreatic duct allows formulation of the typical clinical syndrome, appropriate diagnostic work-up, treatment, and prognosis of patients with these rare lesions. The pancreatic ductal epithelium can present the full spectrum of lesions along the pathogenetic route to malignancy. This is evidence for the presence of an adenoma-to-carcinoma sequence in the pancreas analogous to that which exists in the colon.

Total pancreatectomy for ductal adenocarcinoma of the pancreas with special reference to resection of the portal vein and multicentric cancer

Between March 1, 1968 and March 1, 1986, 323 patients underwent surgery for cancer of the pancreas or the periampullary region. Extirpative procedures were performed in 91 patients, of whom 51 had ductal carcinoma of the pancreas. Forty-seven patients had total pancreatectomy, 9 associated with resection of the portal vein and 1 with total gastrectomy. Operative mortality was 15% but fell to zero for the 19 total pancreatectomies performed after 1981. With the introduction of total pancreatectomy, the resectability rate increased from 15% to 32%. Overall mean survival was 14.4 months. Actuarial survival was 42.4% at 1 year, 25.6% at 2 years, 11.9% at 3 years, and 8% at 5 years. Six patients are alive 7, 11, 14, 30, 30, and 73 months, respectively, after operation. Survival was calculated according to the classifications of Hermreck, Tryka and Brooks, and the TNM system. Ductal carcinoma was multifocal in 32% of patients, and 25% had epithelial dysplasia of the pancreatic duct. When portal vein resection was necessary, mean survival was 6.1 months, compared with 18.25 months when it was not performed. We conclude that total pancreatectomy has increased our resectability rate, mainly in patients with tumor spread beyond the usual margins of division for Whipple's procedure. However, the procedure does not appear worthwhile when portal vein resection is necessary or when multicentric cancer or neoplastic emboli are observed in the operative specimen.

Common difficulties and complications in pancreatic surgery

Pancreatic surgery requires dedicated surgeons to optimize results. Difficult operative situations faced during the course of pancreatic procedures and ways of dealing with them are suggested. The horizons of surgery on the pancreas will expand as the morbidity and mortality rates fall.

The spread and prognosis of carcinoma in the region of the pancreatic head

Tumor infiltration and prognosis were studied in 73 patients who underwent surgery for carcinoma in the region of the pancreatic head, in order to evaluate the grade of malignancy of pancreatic cancer. Twenty three patients had carcinoma of the head of the pancreas, 16 had carcinoma of the intrapancreatic bile duct and 34 had carcinoma of the papilla of Vater. It was found that the prognosis in carcinoma of the head of the pancreas was not related to tumor size, but to lymph node metastasis and the pancreatic capsular or perineural invasion of the tumor. The poorer prognosis seen in carcinoma of the head of the pancreas could be attributed to the fact that lymph node metastasis and invasion of the pancreatic capsule or nerve plexus occurred much more frequently in this carcinoma than in carcinoma of the other two areas. The 5-year survival rate of the patients with carcinoma of the head of the pancreas was 12.5 per cent, this being significantly lower than that of the patients with either carcinoma of the papilla of Vater (50.0 per cent) or carcinoma of the intrapancreatic bile duct (44.4 per cent). These findings suggest that lymph node metastasis and pancreatic capsular or perineural invasion closely correlate with the prognosis of patients with pancreatic carcinoma.

Clinicohistopathologic and immunohistochemical studies of intrapancreatic development of carcinoma of the head of the pancreas

Clinicohistopathologic and immunohistochemical studies of intrapancreatic development of duct cell carcinoma of the head of the pancreas to the body and tail were done in 34 cases in which total pancreatectomy accompanied by portal vein resection were performed from July 1981 to June 1987. In studies of hematoxylin and eosin (HE) staining, intrapancreatic development from the head to the body or tail was observed in 14 cases of 34 cases (41.1%). Multicentricity or skip development was observed in two of 14 cases. However, by using immunostaining of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9) and DUPAN2, small cancer nests surrounded by dense fibrous connective tissues could be easily and accurately diagnosed, and finally, in 25 of 34 cases (73.5%), intrapancreatic continuous development from the head to body or tail was observed. The intrapancreatic development correlated with portal invasion and perineural invasion of carcinoma, hardness of body and tail, obstruction of the main pancreatic duct, and irregular pancreaticogram. The intraoperative quick immunostaining on the cryostat sections, together with HE staining, is useful to determine the intrapancreatic development of the carcinoma. The indication of total pancreatectomy or pancreatoduodenectomy for carcinoma of the head of the pancreas can be determined by these results.

Regional pancreatectomy for cancer of the pancreas, ampulla and other related sites

Regional pancreatectomy refers to an en bloc removal of a tumor in or adjacent to the pancreas with an adequate soft tissue margin and with its regional lymphatic drainage. The pancreatic segment of portal vein is part of the en bloc resection with venous reconstruction by end-to-end anastomosis without a graft. This operation, called a Type I regional pancreatectomy, may utilize either a total or subtotal removal of the pancreas. Localized arterial involvement by a neoplasm necessitates adding a segmental resection of the artery with vascular reconstruction, a Type II procedure. Sixty-one patients have had this procedure from 1972 through December 1982. Thirty-four patients had an infiltrating duct adenocarcinoma of the pancreas, 22 had other malignant tumors, 4 were classified as having pancreatitis, and a fifth had a pseudolymphoma. The resectability rate is about 30 per cent. The present operative mortality rate is 4 per cent by 30 days and 8 per cent after 30 days. One-third of the patients are presently alive; 45 per cent of the 22 patients with malignant tumors other than infiltrating duct adenocarcinoma of the pancreas are alive with a median survival time of 391/2 months ranging from 3 to 92 months. More than 80 per cent of patients with infiltrating duct adenocarcinoma of the pancreas had advanced stage of the disease (T3 or T4 and Stage II or III cancers); twenty-one per cent are presently alive, 29 per cent died of recurrent disease, and 24 per cent died of other causes. The optimal treatment for patients with cancers in the region of the head of the pancreas is a regional subtotal pancreatectomy Type I or Type II followed by adjuvant chemotherapy.