An Aggressive Approach to Locally Confined Pancreatic Cancer: Defining Surgical and Oncologic Outcomes Unique to Pancrea
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ORIGINAL ARTICLE – PANCREATIC TUMORS
An Aggressive Approach to Locally Confined Pancreatic Cancer: Defining Surgical and Oncologic Outcomes Unique to Pancreatectomy with Celiac Axis Resection (DP-CAR) Ryan K. Schmocker, MD, MS1, Michael J. Wright, MS1, Ding Ding, MD, MS1, Michael J. Beckman, MD1, Ammar A. Javed, MD1, John L. Cameron, MD1, Kelly J. Lafaro, MD1, William R. Burns, MD1, Matthew J. Weiss, MD2, Jin He, MD, PhD1, Christopher L. Wolfgang, MD, PhD1, and Richard A. Burkhart, MD1 1
The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD; 2The Division of Surgical Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
ABSTRACT Background. Modern chemotherapeutics have led to improved systemic disease control for patients with locally advanced pancreatic cancer (LAPC). Surgical strategies such as distal pancreatectomy with celiac axis resection (DP-CAR) are increasingly entertained. Herein we review procedure-specific outcomes and assess biologic rationale for DP-CAR. Methods. A prospectively maintained single-institution database of all pancreatectomies was queried for patients undergoing DP-CAR. We excluded all patients for whom complete data were not available and those who were not treated with contemporary multi-agent therapy. Data were supplemented with dedicated chart review and outreach for long-term oncologic outcomes. Results. Fifty-four patients underwent DP-CAR between 2008 and 2018. The median age was 62.7 years. Ninetyeight percent received induction chemotherapy. Arterial reconstruction was performed in 17% and concomitant visceral resection in 30%. The R0 resection rate was 87%. Postoperative complications were common (43%) with chyle leak being the most frequent (17%). Length of stay
This manuscript reflects work selected for presentation at SSO 2020. Society of Surgical Oncology 2020 First Received: 23 April 2020 Accepted: 17 August 2020 R. A. Burkhart, MD e-mail: [email protected]
was 8 days, readmission occurred in one-third, and 90-day mortality was 2%. Disease recurrence occurred in 74% during a median follow up of 17.4 months. Median recurrence-free (RFS) and overall survival (OS) were 9 and 25 months, respectively. Conclusions. Following modern induction paradigms, DPCAR can be performed with low mortality, manageable morbidity, and excellent rates of margin-negative resection in high-volume settings. The profile of complications of DP-CAR is distinct from pancreaticoduodenectomy and simple distal pancreatectomy. OS and RFS are similar to those undergoing resection of borderline resectable and resectable disease. Improved systemic disease control will likely lead to increasing utilization of aggressive surgical approaches to LAPC.
Pancreatic cancer remains a devastating disease and currently represents the fourth leading cause of cancer-related deaths in the United States.1 In 2020, an estimated 57,600 new pancreatic cancer cases and 47,050 pancreas cancer related deaths are expected.1 Unfortunately, the
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