What are the criteria for pancreatectomy (surgical removal of the pancreas)?

From the Guidelines

Pancreatectomy is indicated for patients with resectable pancreatic cancer, defined as a tumor that is localized without distant metastases and demonstrates no involvement of major blood vessels, as stated in the most recent guidelines 1. The criteria for pancreatectomy include the absence of distant metastases and the tumor's resectability, which is determined by its involvement with nearby structures such as major blood vessels.

• The general procedure-related morbidity rate is high at 20% and mortality rate is 1% to 4% 2.
• Less than 20% of patients are candidates for surgery, and for those undergoing surgery, the cancer is often too extensive for removal 2.
• The extent of resection (total versus partial pancreatectomy) depends on the location and nature of the disease, with consideration of the significant metabolic consequences of total pancreatectomy, which results in both endocrine and exocrine pancreatic insufficiency requiring lifelong insulin and pancreatic enzyme replacement.
• Preoperative assessment includes cross-sectional imaging (CT or MRI with pancreatic protocol), endoscopic ultrasound with possible biopsy, and evaluation of functional status with tests like cardiopulmonary exercise testing in high-risk patients.
• The decision to perform a pancreatectomy should be made on a case-by-case basis, taking into account the patient's overall health, the stage and location of the tumor, and the potential benefits and risks of the procedure, as recommended by the REDISCOVER guidelines 1.
• Neoadjuvant chemotherapy may be considered for patients with borderline-resectable or locally advanced pancreatic cancer to improve the chances of a successful resection, as suggested by the REDISCOVER guidelines 1.
• The surgical definition of borderline resectable pancreatic cancer is based on five important observations, including the necessity of complete resection of the primary tumor and regional lymph nodes, and the impact of tumor involvement of the SMV-PV and SMA on resection margins 2.
• The National Comprehensive Cancer Network (NCCN) criteria for resectability/irresectability should be referred to when determining the resectability of a pancreatic tumor 3, 4, 5.
• The American Joint Committee on Cancer (AJCC) has developed staging criteria for adenocarcinoma of the pancreas, which include information that can be determined only through postsurgical pathologic evaluation of resected tumor 5.
• The completeness of the resection should be scored as R0 for complete tumor resection with all margins negative, R1 for incomplete tumor resection with microscopic involvement of a margin, or R2 for incomplete tumor resection with gross residual tumor that was not resected 5.
• The lymph node ratio (LNR) should be indicated, as an LNR ≥ 0.2 is a negative prognostic factor 3, 4.
• Postoperatively, 6 months of gemcitabine or 5-FU chemotherapy are recommended, and patients may also benefit from adjuvant/additive chemotherapy after R1 resection 4.
• Chemoradiation in the adjuvant or additive setting should only be performed within randomized controlled clinical trials 4.
• Neoadjuvant strategies could be useful in patients with resectable tumors, and patients should be encouraged to join clinical trials in this setting 4.
• Patients who develop metastases during neoadjuvant chemotherapy or who progress locally are not candidates for secondary surgery 4.
• The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with borderline-resectable and locally advanced pancreatic cancer, and serve as the basis of a new international registry for this patient population 1.
• The development of effective multiagent chemotherapy regimens has positively impacted the use of resection for patients with borderline-resectable and locally advanced pancreatic cancer, and the administration of chemotherapy in the neoadjuvant setting has become a game changer giving rise to the novel concept of “prognosis-based resectability” 1.
• Following neoadjuvant therapy, pancreatic ductal adenocarcinoma is currently deemed resectable if there is no tumor progression or evidence of tumor regression, a decline of Ca 19.9 levels, and the general conditions of the patients are satisfactory 1.
• In an intention-to-treat analysis, neoadjuvant chemotherapy permitted resection in around 24% of patients with borderline-resectable pancreatic cancer and 9% with locally advanced pancreatic cancer 1.
• This approach allows for a selection based on response to treatment, and oncology guidelines currently suggest considering surgical resection when such control or regression is observed 1.
• While this strategy based on “prognosis-based rationale” may justify a surgical approach to select patients with borderline-resectable and locally advanced pancreatic cancer, it adds new questions regarding the selection and management of these patients during the perioperative period 1.

From the Research

Criteria for Pancreatectomy

The decision to perform a pancreatectomy is based on various factors, including the type and location of the pancreatic disease. Some of the criteria for pancreatectomy include:

• Intractable pain associated with chronic pancreatitis 6
• Multicentric or extensive neuroendocrine tumors 6
• Familial pancreatic cancer with premalignant lesions 6
• Intraductal papillary mucinous neoplasia with diffuse ductal involvement or invasive disease 6
• Benign tumors of the pancreas, such as cystic neoplasms and neuroendocrine tumors 7
• Malignant neoplasms, including pancreatic ductal adenocarcinoma (PDAC) 8

Types of Pancreatectomy

There are different types of pancreatectomy, including:

• Total pancreatectomy: involves the removal of the entire pancreas 6
• Pancreaticoduodenectomy (PD): involves the removal of the head of the pancreas, the duodenum, and other surrounding tissues 7
• Central pancreatectomy (CP): involves the removal of the middle segment of the pancreas 8
• Distal pancreatectomy (DP): involves the removal of the tail of the pancreas 8
• Local resection procedures: such as tumor enucleation, pancreatic middle segment resection, and local, duodenum-preserving pancreatic head resections 7

Considerations for Pancreatectomy

When considering pancreatectomy, several factors should be taken into account, including:

• The risk of postoperative complications, such as bleeding, infection, and pancreatic fistula 9
• The potential for long-term complications, such as diabetes mellitus and pancreatic exocrine insufficiency 7
• The impact of neoadjuvant chemotherapy and radiation therapy on postoperative complications 9
• The importance of preserving pancreatic metabolic functions, particularly in patients with benign tumors 7