Comment améliorer le traitement des adénocarcinomes de la tête du pancréas résécables ?

Pancreatic cancer: French clinical practice guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, AFC)

BACKGROUND

This document is a summary of the French intergroup guidelines regarding the management of pancreatic adenocarcinoma (PA), updated in July 2018.

DESIGN

This collaborative work was produced under the auspices of all French medical and surgical societies involved in the management of PA. It is based on the previous guidelines, recent literature review and expert opinions. Recommendations were graded in three categories, according to the level of evidence.

RESULTS

Over the last seven years, significant changes in PA management have been implemented in clinical practice. Imaging/staging: diffusion magnetic resonance imaging is useful before surgery to rule out small liver metastases.

SURGERY

centralization of pancreatic surgery in expert centers is associated with a decreased postoperative mortality. Adjuvant chemotherapy: modified FOLFIRINOX in fit patients, or gemcitabine, or 5-FU, or gemcitabine plus capecitabine, to be discussed on a case-by-case basis. Locally advanced PA: no survival benefit of chemoradiotherapy. Metastatic PA: FOLFIRINOX and gemcitabine plus nab-paclitaxel combination are first-line standards in fit patients; second-line with 5FU/nal-IRI or 5FU/oxaliplatin combination after first-line gemcitabine.

CONCLUSION

Guidelines for management of PA are continuously evolving and need to be regularly updated. This constant progress is made possible through clinical and translational research. However, as each individual case is particular, they cannot substitute to multidisciplinary tumor board discussion.

Lymph node involvement beyond peripancreatic region in pancreatic head cancers: when results belie expectations

OBJECTIVES

Surgery remains the standard therapy for curative management of pancreatic duct adenocarcinoma (PDA) involving the head of pancreas. This study aimed to report our experience in PDA about the prognostic value of lymph node (LN) invasion (N⁺) at the root of the superior mesenteric artery (SMA) and in N2 subgroup.

METHODS

From January 2005 to September 2009, 110 patients were included for pancreaticoduodenectomy or total pancreatectomy.

RESULTS

Etiologies were PDA (n = 87) or ampullary carcinomas (n = 23). Sixty-five percent of patients were N⁺, with N1/N2/N3 location, respectively, 63.6%, 9.1%, and 2.7%. Forty-four percent had a LN identified intraoperatively at the origin of the SMA, of whom only 12% were N⁺. In multivariate analysis (whole series), complication grade greater than II, location of positive LN (N1 to N3) and vascular resection were associated with a poorer survival. In the exocrine PDA subgroup, only location of positive LN and vascular resection were associated with a poorer survival. N⁺ SMA was not statistically correlated with survival, recurrence, or disease-free survival.

CONCLUSIONS

N⁺ at the origin of the SMA was not a significant prognostic factor for PDA and should no longer be considered as a formal contraindication for curative surgery. Conversely, N2 invasion remains an unfavorable prognostic.

Résultats carcinologiques de l'exérèse chirurgicale du cancer glandulaire céphalique du pancréas

INTRODUCTION

Pancreaticoduodenectomy (PD) is the only curative treatment for adenocarcinoma of the pancreatic head but is associated with a significant early morbidity and a poor long term survival. Therefore, its value is still debated. The aim of this study was to evaluate early and distant results of PD for pancreatic adenocarcinoma, and to identify prognostic factors.

SUMMARY

Seventy-nine patients who underwent PD with curative intent for adenocarcinoma of the pancreatic head from 1982 to 2002 were studied retrospectively. The following data were evaluated: operative mortality, long-term survival, prognostic factors (through univariate and multivariate analysis), and characteristics of 5-year survivors.

RESULTS

Mortality rate was 1.3%. Survival at 1, 3 and 5 years was 46%, 26% and 11%. The median survival was 12 months. The prognostic factors were the T stage (T.N.M. classification) and radicality of resection. After multivariate analysis, radicality of resection was the only independent prognostic factor. Five patients survived for more than 5 years. They did not differ of the other patients but none had positive margin or venous invasion.

CONCLUSIONS

These results (low mortality, significant distant survival including some long term survivors) suggest that PD for pancreatic adenocarcinoma must be indicated in most low-risk patients. PD remains the only curative treatment allowing prolonged survival.