Pancreatic cancer is still a terrifying condition that has a high mortality rate due to its rapid progression and treatment complexity. However, there is still no consensus on what the gold standard of treatment for locally advanced pancreatic cancer (LAPC) is.
The aim of this study was to review the current evidence-based data on treatment strategies for LAPC, comparing pancreatoduodenectomy with vascular reconstruction (PDVR) and chemotherapy alone (CA).
This systematic review was performed according to the PRISMA 2020 guidelines. Overall survival (OS) was the primary endpoint, while progression-free survival (PFS) was the secondary endpoint. The included studies were published between 2013 and 2023.
A total of 16 relevant papers were found in the literature search. The median PFS duration for CA varied from 3.22 to 11.7 months, whereas the median overall survival (mOS) varied from 5.95 to 23.0 months. The mOS ranged from 12.7 to 24.9 months and the median PFS time ranged from 8.5 to 22.5 months for patients submitted to neoadjuvant therapy followed by PDVR.
LAPC presents worse outcomes when patients are submitted to CA with gemcitabine only, or when patients undergo upfront PDVR.
Pancreatic neuroendocrine tumors (PNETs) are uncommon and heterogeneous neoplasms, often exhibiting indolent biological behavior. Their incidence is rising, largely due to the widespread use of high-resolution imaging techniques, particularly influencing the diagnosis of sporadic non-functioning tumors, which account for up to 80% of cases. While surgical resection remains the only curative option, the impact of factors such as tumor grade, size, and type on prognosis and recurrence is still unclear.
To investigate prognostic risk factors and outcomes in patients with sporadic PNETs treated surgically.
A retrospective analysis was conducted on patients with sporadic PNETs who underwent pancreatic resection. Data were collected from medical records.
A total of 113 patients were included: 32 with non-functioning tumors (NF-PNETs), 70 with insulinomas, and 11 with other functioning tumors (OF-PNETs). Patients with insulinoma were significantly younger, had a higher BMI, lower prevalence of comorbidities and ASA scores, and underwent significantly more pancreatic enucleations compared to patients with OF-PNET and NF-PNET. The insulinoma group had more grade I tumors, smaller tumor diameter, lower TNM staging, and lower disease recurrence rates. In univariate analysis, age, tumor type, tumor size, and TNM staging were identified as potential risk factors for tumor recurrence. In multivariate analysis, only the NF-PNET type was identified as an independent prognostic factor for disease recurrence.
NF-PNETs are an independent prognostic risk factor for disease recurrence. This finding supports the need for closer follow-up of patients with small tumors who are selected for conservative management.
Mixed neuroendocrine-non-neuroendocrine tumors (MiNEN) are a rare type of tumor formed by two components, a non-neuroendocrine component that is most often an adenocarcinoma and a neuroendocrine tumor, and each of these components must represent at least 30% of the tumor. The origin of this tumor on the ampulla of Vater or periampullary region is more infrequent. Usually, the lesions are highly aggressive and quickly metastasizing, and their biological behavior is dictated by the high grade of the neuroendocrine component. This is the first report of a patient with ampullary MiNEN treated employing a robotic pancreaticoduodenectomy. Although being submitted to aggressive treatment with complete surgical resection followed by systemic therapy, the patient developed early recurrence with hepatic metastatic disease, demonstrating the hostile nature of these tumors.
Insulinomas are rare neoplasms of the endocrine pancreas. Minimally invasive treatment options for insulinomas have gained prominence, replacing surgical resection due to its associated morbidity and mortality. Radiofrequency ablation (RFA) has emerged as a relevant treatment option. We present a case of a female patient with neuroglycopenic symptoms and severe hypoglycemic crises. The abdominal magnetic resonance imaging (MRI) showed a small nodular lesion in the pancreatic body. Laparotomy was performed, followed by RFA using a 15-mm active-tipped needle. No complications transpired, and no hypoglycemic episodes were observed during 12 months of follow-up.
Carbohydrate antigen 19-9 (CA 19-9), first described in 1979, is a cell surface glycoprotein complex produced by ductal cells in the pancreas, biliary system, and epithelial cells in the stomach, colon, uterus, and salivary glands19. Its expression is only observed in patients with Lewis antigen (Le) A−B+ or Le A+B− blood groups. Up to 6% of the Caucasian and 22% of the non-Caucasian population are genotypically Le A−B− and therefore do not produce CA 19-919.
CA 19-9 is overexpressed in many benign and malignant, gastrointestinal, and extra-gastrointestinal diseases. Its main implications are in pancreatic ductal adenocarcinoma and intraductal papillary mucinous neoplasm (IPMN), but it can also be elevated in biliary, hepatocellular, gastrointestinal, urological, pulmonary, gynecological, thyroid, and salivary gland cancers16. Benign conditions in which CA 19-9 may be elevated include pancreatitis, pancreatic cysts, diabetes mellitus, liver fibrosis, benign cholestatic diseases, and other urological, pulmonary, and gynecological diseases15.
The aim of this article was to present a case of an asymptomatic and exuberant elevation of the CA 19-9 with no identified etiology and a review of the clinical use and implications of the CA 19-9.
Pancreatoduodenectomy after neoadjuvant chemotherapy is the current treatment in patients with borderline pancreatic ductal adenocarcinoma in the head of the pancreas1,2,3. The total mesopancreas excision concept includes the resection of the lymphatic structures on the right side of the SMA and along the neuronal plexus of the pancreatic head. Complete clearance of this retroperitoneal area may increase the R0 resection rate in patients with adenocarcinoma in the head of the pancreas. This area is an important location of perineural infiltration of tumor cells in patients with pancreatic ductal adenocarcinoma4.
Hackert et al5 described the term “triangle operation” as a new surgical technique for patients with locally advanced pancreatic ductal adenocarcinoma and stable disease following neoadjuvant therapy. This area is defined by SMV/PV, celiac axis/common hepatic artery, and SMA, representing the typical view after completion of the resection. However, according to the definition of the authors, the procedure should be performed without arterial resection. Recently, Loss et al6 and Schneider et al7 observed that arterial resection is effective in patients with locally advanced pancreatic cancer after neoadjuvant chemotherapy, with better long-term survival than with palliative treatment. However, this procedure should be performed in experienced pancreatic centers. After neoadjuvant chemotherapy and centers with expertise in pancreatic resection, arterial resection is perfectly possible with acceptable morbidity and mortality.
The solid pseudopapillary neoplasm is a rare tumor of the pancreas. However, it´s etiology still maintain discussions.
To analyze it´s clinical data, diagnosis and treatment.
A retrospective study of medical records of all patients treated from January 1997 until July 2015.
Were identified 17 cases. Most patients were women (94.11%) and the average age was 32.88 years. The main complaint was abdominal mass (47.05%). The most frequent location was in the body/tail of the pancreas (72.22%) and the most frequently performed surgery was distal pancreatectomy with splenectomy (64.70%). No patient had metastases at diagnosis. Conservative surgery for pancreatic parenchyma was performed in only three cases. The rate of complications in the postoperative period was 35.29% and the main complication was pancreatic fistula (29.41%). No patient underwent adjuvant treatment.
The treatment is surgical and the most common clinical presentation is abdominal mass. Distal pancreatectomy with splenectomy was the most frequently performed surgery for its treatment.
The isolate resection of the uncinate process of the pancreas is a rarely described procedure but is an adequate surgery to treat benign and low grade malignancies of the uncinate process of the pancreas.
To detail laparoscopic uncinatectomy technique and present the initial results.
Patient is placed in supine position with the surgeon between legs. Three 5-mm, one 10-mm and one 12-mm trocars were used to perform the isolated resection of the uncinate process of the pancreas. Parenchymal transection is performed with harmonic scalpel. A hemostatic absorbable tissue is deployed over the area previously occupied by the uncinate process. A Waterman drain is placed.
This procedure was applied to an asymptomatic 62-year-old male with biopsy proven low grade neuroendocrine tumor of the pancreatic uncinate process. A laparoscopic pancreaticoduodenectomy was proposed. During the initial surgical evaluation, intraoperative sonography was performed and disclosed that the lesion was a few millimeters away from the Wirsung. The option was to perform a laparoscopic uncinatectomy. Postoperative period until full recovery was swift and uneventful.
Laparoscopic uncinatectomy is a safe and efficient procedure when performed by surgical teams with large experience in minimally invasive biliopancreatic procedures.
Pancreatic neuroendocrine tumors (pNET) correspond to about 3% of all tumors in pancreas and could be presented as a difficult diagnosis and management.
To review the diagnosis and treatment of the pNET available in scientific literature.
A bibliographic survey was performed by means of an online survey of MeSH terms in the Pubmed database. A total of 104 articles were published in the last 15 years, of which 23 were selected as the basis for the writing of this article.
pNET is an infrequent neoplasia and their incidence, in USA, is about 1:100.000 inhabitants/year. Thereabout 30% of them produce hormones presenting as a symptomatic disease and others 70% of the cases could be silent disease. Magnetic Resonance Imaging (MRI) and/or Computed Tomography (CT) have similar sensitivy to detect pNET. They are very important when associated to nuclear medicine mainly Positron Emission Tomography (PET-CT) Gallium-68 to find primary tumor and its staging. The appropriate treatment should be chosen based on characteristics of the tumor, its staging and associated comorbidities.
The surgical resection is still the best treatment for patients with ressectable pancreatic NETs. However, the size, grade, tumor functionality, stage and association with multiple endocrine neoplasia type 1 (MEN-1) are important to define who will be eligible for surgical treatment. In general, tumors bigger than 2 cm are eligible for surgical treatment, except insulinomas whose surgical resection is recommended no matter the size.
Pancreaticoduodenectomy (PD) is a procedure associated with significant morbidity and mortality. Initially described as gastropancreaticoduodenectomy (GPD), the possibility of preservation of the gastric antrum and pylorus was described in the 1970s.
To evaluate the mortality and operative variables of PD with or without pyloric preservation and to correlate them with the adopted technique and surgical indication.
Retrospective cohort on data analysis of medical records of individuals who underwent PD from 2012 through 2017. Demographic, anthropometric and operative variables were analyzed and correlated with the adopted technique (GPD vs. PD) and the surgical indication.
Of the 87 individuals evaluated, 38 (43.7%) underwent GPD and 49 (53.3%) were submitted to PD. The frequency of GPD (62.5%) was significantly higher among patients with pancreatic neoplasia (p=0.04). The hospital stay was significantly shorter among the individuals submitted to resection due to neoplasias of less aggressive behavior (p=0.04). Surgical mortality was 10.3%, with no difference between GPD and PD. Mortality was significantly higher among individuals undergoing resection for chronic pancreatitis (p=0.001).
There were no differences in mortality, surgical time, bleeding or hospitalization time between GPD and PD. Pancreas head neoplasm was associated with a higher indication of GPD. Resection of less aggressive neoplasms was associated with lower morbidity and mortality.
Desenvolvido por Surya MKT