Ann Hepatobiliary Pancreat Surg.  2020 Feb;24(1):90-96. 10.14701/ahbps.2020.24.1.90.

Extended distal pancreatectomy with thoracic wall resection after neoadjuvant FOLFIRINOX: Is there a limit of resection for pancreatic cancer after downstaging?

• Giuliani T
• López Rubio M
• Montalvá Oron E
• Maupoey Ibañez J
• Boscá Robledo A
• López Valdivia C
• Pérez Rojas J
• Lopez Andujar R

• KMID: 2471196
• DOI: http://doi.org/10.14701/ahbps.2020.24.1.90

Abstract

Indications and outcomes of extended pancreatectomies have been recently appraised by the International Study Group for Pancreatic Surgery. However, no definitive conclusions have been drawn, particularly in the setting of neoadjuvant treatments. We present here a case of 53-year-old man diagnosed with a bulky adenocarcinoma of the tail of the pancreas and infiltrating the adjacent organs and the thoracic wall. The patient was sent to neoadjuvant chemotherapy and he underwent 12 cycles of FOLFIRINOX. Since a significant radiological response was observed after chemotherapy, the patient was scheduled for extended distal pancreatectomy with en bloc resection of the thoracic wall, in order to achieve a radical resection. The surgery is herein described with all technical details. The patient was discharged after an uneventful early post-operative course and subsequently readmitted for a late grade B post-operative pancreatic fistula, which was ultimately treated successfully. Pathology showed complete response. When performed in centers with ample experience in pancreatic surgery, extended pancreatic resections represent a viable curative option with acceptable surgical outcomes. In this setting, challenging tailored resections should be considered to achieve negative margins, particularly following maximized effective downstaging strategies.

Keyword

Pancreatic surgery; FOLFIRINOX; Extended pancreatectomy; Multivisceral resection

MeSH Terms

Adenocarcinoma
Drug Therapy
Humans
Middle Aged
Neoadjuvant Therapy
Pancreas
Pancreatectomy*
Pancreatic Fistula
Pancreatic Neoplasms*
Pathology
Tail
Thoracic Wall*

Figure

• 

  Fig. 1 Axial (A) and coronal (B) CT scan images performed at diagnosis showed a bulky tumor (arrows) of the pancreatic tail involving the surrounding organs and the abdominal wall.

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  Fig. 2 Axial (A) and coronal (B) CT scan images performed at the end of neoadjuvant treatment showed a significant reduction of the tumor size (arrows) as well as a decreased involvement of adjacent organs.

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  Fig. 3 (A) The transverse colon was transected with a linear stapler. (B) The pancreatic transection was performed by a reinforced stapler. (C) Closure of the pancreatic stump. (D) Left renal artery and vein were divided. (E) Left ureter was identified and divided.

• 

  Fig. 4 (A, B) Left thoracotomy was performed and the 9th and the 10th ribs were transected. (C) Pancreatic dissection was extended to left up to the thoracic wall. (D) The specimen was removed en bloc and a wide diaphragmatic defect was observed. (E) The thoracotomy and the diaphragmatic defect were directly repaired.

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  Fig. 5 (A) The macroscopic analysis (A) of the specimen included the tail of the pancreas (P), the spleen (S), the left kidney, the left colonic flexure (C) the left adrenal and the thoracic wall resection. Peripancreatic fat (F) is also shown. (B) Histological exam with H&E stain revealed complete response with diffuse fibrosis. No viable tumor cells were detected.

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