Keywords:
Neoadjuvant therapy - Pancreatic neoplasms - Surgery.
Descritores:
Terapia neoadjuvante - Neoplasias pancreáticas - Cirurgia.
INTRODUCTION
Approximately 57,600 people develop exocrine pancreatic cancer each year in the United
States and more than 90% of them are expected to die from their disease.([1]) The most common histological type is pancreatic ductal adenocarcinoma (PDAC), responsible
for more than 85% of cases. Surgical resection is the only potentially curative treatment.
Unfortunately, due to the late presentation of the disease, only 15 to 20% of patients
are candidates for pancreatectomy.([2])
Vascular involvement is related to the low rates of resectability observed in the
disease, but its relationship with the prognosis is controversial. Resection of the
portal vein (PV) and superior mesenteric vein (SMV) combined with pancreatectomy is
a safe and viable procedure, which may increase the number of patients undergoing
potentially curative resection and, therefore, provides important survival benefits
for selected cases.([3]
[4]) On the other hand, few data in the literature are available to support arterial
resection in PDAC. Surgical treatment in these cases is infrequent and when performed,
it is related to an increase in morbidity and mortality.([5]
[6])
Currently, chemotherapy has been the initial treatment with locally advanced or unresectable
PDAC. The approach aims to “shrinkage the tumor volume” before surgical exploration
using chemotherapy with or without RT. As demonstrated in ESPAC-5F, a prospective,
multicenter international phase II randomized four-arm clinical trial that compared
immediate surgery with gemcitabine neoadjuvant plus capecitabine (GEMCAP) or FOLFIRINOX
or chemoradiotherapy (CRT) in PDAC with borderline resectable disease. The results
demonstrated the one-year survival rate was 40% [95% CI, 26%-62%] for immediate surgery
and 77% [95% CI, 66%-89%] for neoadjuvant therapy.([7]) Regarding to the addition of RT in the neoadjuvant treatment, unfortunately, it
is not known whether it contributes to the R0 resection rate in patients treated with
aggressive combination regimens, such as FOLFIRINOX.([7]
[8])
We present a case of PDAC with invasion of the celiac axis (CA) treated with surgical
resection after proven disease stability with neoadjuvant chemotherapy, despite the
controversies and challenges on the subject.
CASE REPORT
A 42-year-old, female, previously healthy patient presented with low back pain on
the right and 7kg weight loss for 4 months. Contrast-enhanced CT showed a nodule in
the body of the pancreas 2.6x2.4cm involving the bifurcation of the CA. Anatomical
variations were not observed ([Figure 1]) and CA 19-9 was in 130. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA)
evidenced nodule of the pancreas body of 3,2x3,0cm and the involvement of the splenic
artery emergence near the celiac trunk with histopathologic findings adenocarcinoma.
PET scan showed the nodule of the pancreas body with SUV 5,8 ([Figure 2]).
Figure 1 Contrast-enhanced CT showed a nodule in the body of the pancreas 2.6x2.4 cm involving
the bifurcation of the celiac axis
Figure 2 Positron emission tomography (PET) scanning showed the nodule of the pancreas body
with SUV 5,8
After multidisciplinary discussion, we decided to start treatment for this clinical
staging III-cT4N0M0 patient, with chemotherapy consisting of 3 cycles of the FOLFIRINOX
regimen. In her tumor access after chemotherapy, the patient was classified by the
RECIST 1.1 method as a stable disease.
Surgical exploration was carried out on September 2016, it took place without complications
for duration of 240min and without the need for blood transfusion. Preoperative preparation
included a vaccine against encapsulated germs. After complete the dissection and repair
the vascular structures, surgery included a block resection of the body and tail of
the pancreas, celiac axis and branches, spleen and stomach (Roux-en-Y reconstruction).
Primary anastomosis of common hepatic artery (CHA) with CA was made and suture of
the stump and pancreatic duct ([Figure 3]). Histological work-up revealed R0 resection, PDAC, G2, and ypT4N1Mx.
Figura 3 Photographs showing pancreatic stump, superior mesenteric vein, primary arterial
anastomosis of the common hepatic artery with celiac axis
The patient's clinical course was uneventful, only transient alteration of liver functions,
remaining in the intensive care unit for 48 hours and being discharged on the 9th postoperative day. It evolves without pancreatic fistula but with weight loss and
difficult to control diarrhea managed with pancreatic enzyme replacement and nutritional
support. Received adjuvant CRT (gemcitabine plus RT) due to the high-risk of developing
metastases.
After 30 months of oncological follow-up, the patient evolved with an elevation of
CA19.9 - 3000. Restaging tests and EUS-FNA biopsy showed hepatic and peritoneal recurrence.
FOLFIRINOX in an adjusted dose was administered until disease progression followed
by sequential treatments of gemcitabine and capecitabine managed through disease progression
and death on March 2020.
DISCUSSION
Long-term survival of PDAC after surgery is still rare. One of the main reasons for
unresectability is the tumor involvement of the main vessels, such as the CA, CHA,
and SMA.([5]) The optimal management of these patients is controversial, and there is no standard
approach.([9])
The aim of the staging workup is to delineate the extent of disease spread and identify
patients who are eligible for resection or preoperative treatment.([10]) Imaging exams should analyzed with special attention to vascular variations of
the CHA, because, when not detected, may represent a risk of accidental iatrogenic
injury in vessels with consequent hepatic infarction.([11]) An initial assessment of resectability can usually be made based upon the CT scan
or magnetic resonance imaging (MRI). The utility of positron emission tomography (PET)
scans in the staging of suspected PDAC remains controversial.([12])
The lack of staging laparoscopy did not compromise the outcome of the treatment of
this case. However, based on current data, this approach should be used([13]) with occult metastases identified in 29% of patients with resectable tumor on CT
scan.([14])
EUS-FNA or CT-guided percutaneous core needle biopsy (CT-CNB) is mandatory and provide
histologic diagnostic before neoadjuvant therapy, as well an assessment of the serum
levels of CA 19-9.([12]) This approach increase the amount of patients becoming eligible for surgery, avoiding
unnecessary operations on tumors with aggressive biology that evolve despite neoadjuvant
therapy.([2])
Tumors with limited venous involvement, resection of the portal vein (PV), and superior
mesenteric vein (SMV) combined with pancreatectomy provide an increase in the number
of patients undergoing potentially curative resection and, therefore, important survival
benefits for selected cases.([3]
[4]) On the other hand, unresectable PDAC with arterial involvement, resections are
performed infrequently, with most of tumors treated non-surgically with chemotherapy
or chemotherapy associated with radiotherapy (CRT).([15]
[16])
The 5-year overall survival (OS) for metastatic PDAC remains at 2%,([15]
[16]
[17]) with a median life expectancy of <1 year with current treatments.([18]
[19]) In our report, the patient underwent pancreatectomy with vascular resection of
CA after neoadjuvant therapy. Received adjuvant CRT (gemcitabine plus RT) due to the
high risk of developing metastases. Concerning, hepatic artery reconstruction, albeit
postoperative liver infarction is unusual, it is a potentially deadly complication.
There are some reports standing the use of preoperative hepatic artery embolization
or hepatic common artery ligation by laparoscopy to promote development of collateral
pathways prior to pancreatectomy with hepatic artery resection.([20]) Due to this specific approaches, hepatic artery reconstruction could be avoided
in few previous accessed cases.
In our report, after perform a primary anastomosis of CHA with CA, a total gastric
resection was the option founded to remediate fund gastric ischemia, arising from
splenic and left gastric artery ligation. The right gastroepiploic arcade was not
enough to provide fund gastric irrigation and the patient did not have a distal left
gastric artery stump with matching gauge to allow anastomosis without microsurgery.([21])
CONCLUSION
Although complex, pancreatectomy with vascular resection proved to be viable with
acceptable morbidity in our service. The OS achieved in our report was 42 month. To
maximize the result, it was mandatory a careful selection of the patient, neoadjuvant
chemotherapy, and adequate radiological evaluation.
Bibliographical Record
Renato Morato Zanatto, Patrícia Medeiros Milhomem Beato, Maurício José Vieira, Celso
Roberto Passeri. Distal pancreatectomy with celiac axis resection for locally advanced
pancreatic carcinoma: case report. Brazilian Journal of Oncology 2021; 17: e-20210017.
DOI: 10.5935/2526-8732.20210017
