Radical surgery of oligometastatic pancreatic cancer

https://doi.org/10.1016/j.ejso.2016.10.023Get rights and content

Abstract

Background

In metastatic disease (M1), chemotherapy (expected survival: 6–10 months) is considered the only treatment option. The aim of this study was to evaluate the outcome of curative M1 PDAC resections.

Methods

Prospective data of all patients undergoing primary tumour and metastasis resection for stage IV PDAC during a 12-year period was analysed regarding localisation (liver or distant interaortocaval lymph nodes; ILN), morbidity and survival. Patients were stratified with regard to syn- or metachronous metastases resection.

Results

Patients (n = 128) undergoing PDAC and metastases resection (intention-to-treat, oligometastatic stage; liver n = 85; ILN n = 43) were included. Surgical morbidity and 30-day mortality after synchronous resection of M1 tumours were 45% and 2.9%, respectively. Overall median survival after M1 resection was 12.3 months in both groups. Long-term outcome showed a 5-year survival of 8.1% after surgery for both liver metastases and 10.1% following ILN resection.

Conclusions

The present collective is the largest series of resected metastatic PDAC and shows that resection of liver or ILN metastases can be done safely and should be considered as it may be superior to palliative treatment, and it is associated with long-term survival of 10% in selected patients. Further studies to stratify patients for these procedures are warranted.

Introduction

Pancreatic ductal adenocarcinoma (PDAC) remains a challenging disease with a poor prognosis1. Despite improved medical treatment options and the significant impact of adjuvant chemotherapy, surgery remains the only basis on which long-term survival can be achieved2. Surgery is limited to patients presenting with localised disease, and metastatic spread is generally regarded as a contraindication for resection, regardless of whether it is synchronously or metachronously observed3. Despite this, metastases resection or local therapy is occasionally performed by centres around the world based on individual decisions without existing evidence regarding patient selection or the extent of metastatic spread4, 5, 6, 7, 8. Most commonly, PDAC metastases are present in the liver, interaortocaval lymph nodes (ILN) or the peritoneum. As peritoneal metastases are intraoperatively found to be diffusely spread in most cases, no surgical approach is possible in most patients. In contrast, a resection of liver metastases is often possible without major surgical trauma, e.g. for subcapsular lesions that are found during intraoperative exploration. In addition, ILN metastases – currently defined as distant metastases – are regarded as an indication to stop resection when proven positive in an intraoperative frozen section9, 10, although evidence on the prognostic value of these lymph nodes remains controversial11 and resection is not technically challenging.

The aim of the present study was to analyse the impact of resection therapy in stage IV PDAC patients with limited metastases located in the liver or the interaortocaval lymph nodes in terms of surgical outcome and long-term survival.

Section snippets

Methods

Prospectively collected data of all patients undergoing surgery for PDAC at the Department of Surgery, University of Heidelberg, between October 2001 and May 2014 were analysed. Patients who underwent primary tumour and metastasis resection for stage IV PDAC with metastatic spread to the liver or within the interaortocaval lymph nodes were extracted. They were investigated regarding the following: localisation of metastases (liver or interaortocaval lymph nodes; ILN); primary tumour resection;

Baseline characteristics

One hundred and twenty-eight patients undergoing surgery for stage IV PDAC with spread to the liver or the ILN were identified in the observation period, with a mean age of 61 years; 48% of the patients were male. Regarding the subgroups of liver and ILN metastases, no differences in these parameters were found. Furthermore, there were no differences regarding preoperative body mass index or American Society of Anesthesiologists' (ASA) classification between the groups (Table 1).

All patients

Discussion

The present study includes the largest collective of patients resected for stage IV PDAC to date and shows a survival benefit for selected patients with liver or ILN metastases compared to reported survival times after palliative treatment alone. Importantly, 5-year survival was 10% of the patients in both groups, which has never been reported following any type of chemotherapy regimen alone.

According to international guidelines and widespread clinical practice, stage IV PDAC patients are

Conflict of interest statement

The authors have no disclosures.

References (32)

  • A.L. Gleisner et al.

    Is resection of periampullary or pancreatic adenocarcinoma with synchronous hepatic metastasis justified?

    Cancer

    (2007)
  • M.C. De Jong et al.

    Liver-directed therapy for hepatic metastases in patients undergoing pancreaticoduodenectomy: a dual-center analysis

    Ann Surg

    (2010)
  • J. Edwards et al.

    Combined pancreas and liver therapies: resection and ablation in hepato-pancreatico-biliary malignancies

    J Surg Oncol

    (2013)
  • M.F. Nentwich et al.

    Surgery for advanced and metastatic pancreatic cancer–current state and trends

    Anticancer Res

    (2012)
  • Y. Murakami et al.

    Prognostic impact of para-aortic lymph node metastasis in pancreatic ductal adenocarcinoma

    World J Surg

    (2010)
  • R.K. Pai et al.

    Pattern of lymph node involvement and prognosis in pancreatic adenocarcinoma: direct lymph node invasion has similar survival to node-negative disease

    Am J Surg Pathol

    (2011)
  • Cited by (0)

    a

    These authors contributed equally.

    View full text