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The Oncologist, Vol. 12, No. 6, 654-663, June 2007; doi:10.1634/theoncologist.12-6-654
© 2007 AlphaMed Press

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Gastrointestinal Cancer

Extended Resection for Pancreatic Adenocarcinoma

Srinevas K. Reddy, Douglas S. Tyler, Theodore N. Pappas, Bryan M. Clary

Duke University Medical Center, Durham, North Carolina, USA

Key Words. Pancreatic neoplasms • Pancreatic ductal carcinoma • Pancreaticoduodenectomy • Pancreatectomy Lymph node excision • Portal vein

Correspondence: Bryan Clary, M.D., Duke University Medical Center, Box 3247, Durham, North Carolina 27710, USA. Telephone: 919-684-6553; Fax: 919-681-7508; e-mail: clary001{at}mc.duke.edu

Adenocarcinoma of the pancreas presents a number of therapeutic challenges. Given the poor long-term outcomes after pancreaticoduodenectomy (PD), many surgeons have sought to improve survival via a radical or "extended" pancreatectomy which may include (a) total pancreatectomy (TP), (b) extended lymph node dissection (ELND), and (c) portal/mesenteric vascular resections. These themes of "extended" resection are addressed in this review.

TP should not be performed for most cases of adenocarcinoma of the pancreatic head because of the nominal incidence of lymph node involvement along the body and tail of the pancreas, the scarcity of multicentric disease, and the better management of pancreatic leaks after PD. Most studies show no difference in long-term survival and demonstrate greater postoperative morbidity after TP than after PD. Performing ELND in addition to PD is not worthwhile because most studies do not demonstrate any long-term benefits from ELND and the circumferential dissection around the mesenteric vessels required to harvest distant lymph nodes increases postoperative morbidity. Major arterial resection increases postoperative morbidity after PD and worsens long-term survival as the need for arterial resection to achieve negative resection margins indicates more aggressive disease. In contrast, portal and/or mesenteric venous resection does not increase the morbidity after PD or impact long-term survival as venous resection is often performed because of tumor location and not extent of disease. The disappointing experience with extended resections underscores the need for better adjuvant systemic strategies and the interdisciplinary care of patients with pancreatic adenocarcinoma.

Disclosure of potential conflicts of interest is found at the end of this article.






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