Multimodal treatment combining neoadjuvant therapy, laparoscopic subtotal distal pancreatectomy and adjuvant therapy for pancreatic neck-body cancer: Case series

Abstract

Background: Pancreatic cancer involving the pancreas neck and body often invades the retroperitoneal vessels, making its radical resection challenging. Multimodal treatment strategies, including neoadjuvant therapy, surgery, and postoperative adjuvant therapy, are contributing to a paradigm shift in the treatment of pancreatic cancer. This strategy is also promising in the treatment of pancreatic neck-body cancer.

Aim: To evaluate the feasibility and effectiveness of a multimodal strategy for the treatment of borderline/locally advanced pancreatic neck-body cancer.

Methods: From January 2019 to December 2021, we reviewed the demographic characteristics, neoadjuvant and adjuvant treatment data, intraoperative and postoperative variables, and follow-up outcomes of patients who underwent multimodal treatment for pancreatic neck-body cancer in a prospectively collected database of our hospital. This investigation was reported in line with the Preferred Reporting of Case Series in Surgery criteria.

Results: A total of 11 patients with pancreatic neck-body cancer were included in this study, of whom 6 patients were borderline resectable and 5 were locally advanced. Through multidisciplinary team discussion, all patients received neoadjuvant therapy, of whom 8 (73%) patients achieved a partial response and 3 patients maintained stable disease. After multidisciplinary team reassessment, all patients underwent laparoscopic subtotal distal pancreatectomy and portal vein reconstruction and achieved R0 resection. Postoperatively, two patients (18%) developed ascites, and two patients (18%) developed pancreatic fistulae. The median length of stay of the patients was 11 days (range: 10-15 days). All patients received postoperative adjuvant therapy. During the follow-up, three patients experienced tumor recurrence, with a median disease-free survival time of 13.3 months and a median overall survival time of 20.5 months.

Conclusion: A multimodal treatment strategy combining neoadjuvant therapy, laparoscopic subtotal distal pancreatectomy, and adjuvant therapy is safe and feasible in patients with pancreatic neck-body cancer.

Keywords: Adjuvant therapy; Laparoscopic subtotal distal pancreatectomy; Multimodal treatment; Neoadjuvant therapy; Pancreatic neck-body cancer.

Figure 1

Flowchart for multimodal treatment of borderline/locally advanced pancreatic neck-body cancer. MDT: Multidisciplinary team; SMV: Superior mesenteric vein; PV: Portal vein.

Figure 2

The definition of pancreatic subdivisions. A: The pancreatic subdivisions were defined as follows: Pancreatic head, right to the portal vein (PV)/superior mesenteric vein (SMV); pancreatic neck, in front of the PV/SMV; pancreatic body, left of the PV/SMV to left of the abdominal aorta; pancreatic tail, left of the abdominal aorta; B: Pancreatic cancer involving the neck and body of the pancreas; pancreatic cancer (yellow arrow), portal vein (blue arrow). PV: Portal vein; GDA: Global domain adaptation; CBD: Common bile duct; SMV: Superior mesenteric vein; Ph: Pancreatic head; Pn: Pancreatic neck; Pb: Pancreatic body; Pt: Pancreatic tail; CHA: Common hepatic artery; CA: Celiac artery; LGA: Left gastric artery; SA: Spleen artery; AA: Abdominal aorta; SMA: Superior mesenteric artery.

Figure 3

Changes in pancreatic lesions before and after neoadjuvant therapy. A and B: Case 1; C and D: Case 2. Yellow arrows indicate the lesions.

Figure 4

Laparoscopic subtotal pancreatectomy with portal vein/superior mesenteric vein reconstruction. A: The artery-first approach was applied in our laparoscopic subtotal pancreatectomy; B: Schematic diagram of the pancreas transection plane for laparoscopic subtotal pancreatectomy; C: We transected the pancreas along the left edge of the common bile duct during surgery; D: The involved portal vein was resected, rapid frozen section pathology confirmed no residual tumor cells at the portal vein transection margin; E: End-to-end anastomosis of the portal vein was performed, the soft tissues adjacent to the tumor in the Heidelberg triangle were removed; F: The posterior plane of resection was behind the left adrenal gland and Gerota’s fascia (similar to the posterior radical antegrade modular pancreatosplenectomy). SMA: Superior mesenteric artery; CBD: Common bile duct; CA: Celiac artery.