Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA.
J Am Coll Surg. 2012 Jul;215(1):41-51; discussion 51-2. doi: 10.1016/j.jamcollsurg.2012.03.024. Epub 2012 May 18.
Patients identified at surgical exploration with unresectable pancreatic ductal adenocarcinoma receive palliative, noncurative therapy. We hypothesized that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients deemed unresectable at previous exploration the possibility for curative salvage pancreatectomy.
Review of a prospectively maintained pancreatic ductal adenocarcinoma database identified all patients (1990 to 2010) evaluated after being deemed unresectable at first exploration elsewhere. Referring hospitals were categorized per National Cancer Data Base criteria as academic, community, or international. Patients were restaged using objective imaging (CT) criteria and classified based on anatomic resectability. Clinicopathologic factors and cancer-related outcomes were assessed.
We evaluated 88 patients who underwent previously unsuccessful resection attempts at academic (n = 50), community (n = 25), and international (n = 13) centers. Radiographic restaging confirmed that 7 (8%) patient tumors were locally advanced and unresectable, but 81 (92%) were resectable (n = 61) or borderline resectable (n = 20). Using a surgery first (9%) or preoperative chemoradiation (91%) approach, successful reoperative pancreatectomy was performed in 66 (81%) patients, with 94% receiving R0 resections. Vascular resection/reconstruction was required in 30 (46%) patients and 50 (76%) required complex revision of previously created biliary/gastrointestinal bypass. The major complication rate was 20% and 3 (4.5%) patients died perioperatively. Median overall survival was 29.6 months for successfully resected patients vs 10.6 and 5.1 months (p < 0.0001) for those patients with locally advanced unresectable disease at initial referral or in whom metastatic disease developed before resection, respectively.
In this very selected cohort of high-risk patients, the majority had anatomically resectable tumors on restaging. Accurate radiographic restaging, a multimodality treatment strategy, and advanced surgical techniques can provide an opportunity for cure in a substantial proportion of select patients who were deemed unresectable at exploration.
在手术探查中被诊断为无法切除的胰腺导管腺癌患者接受姑息性非治愈性治疗。我们假设，准确的影像学再分期、多模式治疗和先进的手术技术可以为之前在其他地方被认为无法切除的患者提供治愈性胰切除术的可能性。
回顾性分析了一个前瞻性维持的胰腺导管腺癌数据库，该数据库中包括了所有在其他地方首次探查被认为无法切除的患者（1990 年至 2010 年）。参考医院按国家癌症数据库标准分为学术、社区或国际。使用客观影像学（CT）标准对患者进行再分期，并根据解剖可切除性进行分类。评估了临床病理因素和癌症相关结局。
我们评估了 88 名在学术（n=50）、社区（n=25）和国际（n=13）中心进行过先前不成功切除尝试的患者。影像学再分期证实，7（8%）例患者肿瘤局部晚期且无法切除，但 81（92%）例患者可切除（n=61）或边界可切除（n=20）。采用手术先行（9%）或术前放化疗（91%）方法，成功进行了 66（81%）例再手术胰切除术，94%的患者获得了 R0 切除。30（46%）例患者需要血管切除/重建，50（76%）例患者需要复杂的先前创建的胆肠旁路重建。主要并发症发生率为 20%，3（4.5%）例患者围手术期死亡。成功切除患者的中位总生存期为 29.6 个月，而初始转诊时局部晚期无法切除疾病的患者和在切除前发生转移疾病的患者分别为 10.6 个月和 5.1 个月（p<0.0001）。
在这个高度选择的高危患者队列中，大多数患者在再分期时具有解剖学可切除肿瘤。准确的影像学再分期、多模式治疗策略和先进的手术技术可以为在其他地方被认为无法切除的患者提供治愈的机会。
