Is the tail of the pancreas always tumor-infiltrated when macroscopically affected during cytoreductive surgery? A clinicopathological study and experience from a high-volume center

Abstract

Background: Distal pancreatic resection during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is rare, with limited knowledge available. Therefore, a retrospective observational study was conducted using the data registry of a single institution to identify patients that underwent distal pancreatic resection during CRS + HIPEC.

Methods: All resected pancreatic specimens were examined for invasive parenchymal tumor infiltration. Pre-, peri-, and postoperative variables and their associations were analyzed.

Results: Over a period of more than a decade, 31 of 1275 patients (2.43%) underwent distal pancreatic resection as part of CRS. Infiltration of the pancreatic parenchyma was confirmed in almost one-third (29.03%) of the cases. Postoperative pancreatic fistulas occurred in 25.81% of patients (87.5% Grade B; 12.5% Grade C). The need for distal pancreatic resection was closely related to tumor burden in the left upper abdomen, with 87% of patients requiring peritonectomy of the left upper abdomen in addition to visceral resection. Pancreatic infiltration (n = 9/31) was diagnosed in 3 cases of gastric carcinoma, 2 cases of colorectal carcinoma, 2 cases of primary peritoneal carcinoma, 1 case of ovarian carcinoma, and 1 case of mucinous appendiceal carcinoma. Postoperative pancreatic fistulas were more frequently associated with primary tumors of the large intestine (87.50% vs. 30.43%; P = 0.0094), and a tendentiously longer total hospital stay was required for the "with pancreatic fistula" group (32.50 ± 19.93 days vs. 21.78 ± 10.14 days), with no impact on patient survival.

Conclusions: Accepting a slightly increased morbidity, distal pancreatic resection is a reasonable approach to achieve complete macroscopic tumor resection. Nonetheless, our study shows that apparent tumor invasion is histologically rare in cases with favorable tumor biology, such as low-grade pseudomyxoma peritonei. Therefore, pancreatic resection should be avoided in cases of mucinous tumors to prevent fistula formation.

Keywords: Cytoreductive surgery; Hyperthermic intraperitoneal chemotherapy; Pancreatic fistula; Pancreatic tail resection; Peritoneal surface malignancy.

Fig. 1

Lower peritoneal cancer index values were found in those patients without invasive parenchymal tumor infiltration of the pancreas (crude P = 0.0322; A), and tendentiously longer total hospital stay was observed in the case of those patients where postoperative pancreatic fistula developed (crude P = 0.0969; B)

Fig. 2

Overall survival of the study population grouped on the presence of invasive parenchymal tumor infiltration. In the comparison, no difference could be justified between the two subgroups

Fig. 3

Microscopically, atypical ductal neoplastic proliferates infiltrate both peripancreatic fibro-lipomatous (yellow star) and pancreatic tissues (red star). The neoplastic invasive growth is associated with fibrosis and regressive changes of soft tissues (embedding in paraffin wax, staining method: hematoxylin-eosin, original magnification: ×4)