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World J Gastroenterol 2001;7(5):622-626 World Journal of Gastroenterology Copyright © 2001 by The WJG Press ISSN 1007-9327
• REVIEW •
Recent advances in the surgical treatment of pancreatic cancer A Shankar and RCG Russell Department of Surgery, The Middlesex Hospital, Mortimer Street, London, W1N 8AA, UK Correspondence to: A Shankar, Department of Surgery, The Middlesex Hospital, Mortimer Street, London, W1N 8AA, UK Received 2001-05-15 Accepted 2001-06-15
Subject headings pancreatic neoplasms/surgery; pancreatic neoplasms/diagnosis Shankar A, Russell RCG. Recent advances in the surgical treatment of pancreatic cancer. World J Gastroenterol, 2001;7(5):622-626
INTRODUCTION Pancreatic cancer remains the fourth commonest cause of cancer related death in the western world[1]. The prognosis remains dismal due partly to late presentation, with associated low resectability rates, and the aggressive biological nature of these tumors. The median survival time from diagnosis in unresectable tumors remains only 4-6 months. For those patients amenable to surgical resection over the last 20 years have seen marked improvements in postoperative mortality and morbidity, especially in specialist pancreatic centres[2,3]. Despite these changes long-term survival remains low, with a total 5-year survival rate remaining less than 5%. Patients with ampullary cancer have a better 5-year survival of 40%-60%. Resection, however, remains the only chance of long term survival with adjuvant therapies providing disappointing results. Operability remains low due to the local and distant extent of the disease. Assessment of this extent has been greatly advanced by modern radiological techniques. PREOPERATIVE ASSESSMENT Once distant disease has been excluded, selection of patients for resection is crucial if the rate of irresectability discovered at operation is to be kept to a minimum. Angiography Once considered crucial in the assessment of operability, angiography is now virtually unnecessary. It was argued that the venous phase of the arteriogram was fundamental if invasion of the superior mesenteric and portal vein were to be excluded. This has now been superseded by improvements in helical CT scanning, which is able to accurately determine venous involvement. The issue of preoperative detection of vascular anomalies should not be an indication for routine angiography in the hands of experienced pancreatic surgeons. Computerised tomography (CT) CT is still the traditional imaging modality for staging pancreatic cancer, although it lacks specificity and sensitivity. Spiral CT with intravenous contrast offers higher resolution than conventional CT and improves diagnostic and staging accuracy[4]. Unfortunately CT is still limited by its ability to
differentiate between benign and malignant lesions and also may miss subcentimetre hepatic deposits and peritoneal seedlings. The impact of helical CT scanning using defined pancreatic protocols with multiplanar reconstruction has yet to be assessed, but the extent of local disease, involvement of arteries and veins and lymphatic spread can be assessed with improved accuracy (as illustrated in the following CT images).
Magnetic resonance imaging (MRI/MRCP) Although a relatively new technique for assessing pancreatic lesions, MRI is particularly useful at differentiating inflammatory from neoplastic pancreatic lesions. Pancreatic adenocarcinomas are usually low signal on T1 and T2 weighted images[5], although it has as yet not been shown to be superior to CT in assessing operability. The use of magnetic resonance endoscopy may in the future improve the accuracy of MRI. At present, both MRI and CT scanning give additional information such that both techniques are of value in assessment. Laparoscopy and laparoscopic ultrasound Laparoscopy has the advantage of being able to detect small (
