General aspects of surgical treatment of pancreatic cancer

BACKGROUND: Different results and opinions exist concerning the use of a standard or an extended lymphadenectomy, and about the indications for portal vein resection in the surgical treatment of pancreatic cancer. The site of recurrence of pancreatic cancer may help to define the usefulness of different treatments in avoiding local and/or distant recurrences. METHODS: From personal experience and a literature review, 841 patients who underwent portal vein resection were collected, and 29 papers reporting the results of extended lymphadenectomy in the surgical treatment of pancreatic cancer were analyzed. A review of the site of relapse according to the surgical treatment, with or without various adjuvant treatments, was performed. Personal experience on survival rate according to the site of relapse (local, distant, local and distant) is also reported. RESULTS: Portal vein resection has been performed without a significant increase in morbidity and mortality rate in a large number of patients. However, its usefulness for increasing the resectability rate and the long-term survival has yet to be established. Extended lymphadenectomy does not increase the morbidity and mortality rate, but conflicting results on long-term survival have been reported. Distant metastases, undetectable by the radiologist and the surgeon, usually kill more than 40% of the resected patients within 12 months. Only lymph node-positive patients with limited undetectable distant metastases seem to benefit from an extended lymphadenectomy. Although many data are lacking, the incidence of the different sites of relapse is the same whatever the surgical and/or adjuvant treatment performed. Overall survival and disease-free survival rate are not affected by the site of relapse. A significantly worse survival rate was observed after the radiological detection of local and distant metastasis than after an only local or only distant metastasis. CONCLUSION: Portal vein resection and extended lymphadenectomy can be performed without increasing the surgical morbidity and mortality rate. We still have insufficient data to decide which patient can benefit from a more extended procedure. Standardization of operations, terminology, pathological reporting, and follow-up, together with well-designed prospective studies, will help to decide the operation of choice for pancreatic cancer.