Borderline resectable pancreatic cancers- aggressive pancreatic surgery involving vascular resection & reconstruction

Pancreatic cancer is more often detected at an advanced stage.; wherein tumor is spread locally or systematically. In a large number of patients with pancreatic cancer, the tumor is in contact with nearby blood vessels like portal / superior mesenteric vein, hepatic artery, superior mesenteric artery and celiac artery. The tumor may come in contact with one or more of these at the same time. Also it may be only abutting, surrounding, invading the vessel wall on one side or circumferentially encasing. Depending on the extent of involvement; the disease is labelled as borderline resectable (limited involvement) or locally advanced (significant involvement). Locally advanced disease is always initially treated by chemotherapy or chemo radiation. Very few of these locally advanced disease patients may become eligible for surgery after initial therapy. Surgery involves resection of tumor with the involved blood vessel. Later on chemotherapy has to be continued.

Borderline resectable tumors may be treated by upfront / initial surgery followed by chemotherapy or patient may receive initial chemotherapy (neoadjuvant) followed by surgery further followed by chemotherapy (adjuvant). Surgery involves resection of part of or complete vessel followed by reconstruction of the vessel where necessary. This is extremely complex work, takes long hour surgery, involves an arduous long drawn recovery process with high complication risk and significant expenses. This is possible in very few patients. We would like to share 2 of our such interesting cases of borderline resectable pancreatic cancer for interested readers.

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Case 1

48 year old gentleman presented with cancer involving body and tail of pancreas. The tumor was encasing (circumferentially involving) the origin of hepatic artery (supplying oxygenated blood to liver), splenic artery and left gastric artery when originating from the celiac axis. The surgery was possible upfront; however in view of possible postoperative complications which delay the chemotherapy, patient was first given few cycles of chemotherapy. Patient was later operated wherein the tumor bearing portion of body and tail of pancreas along with spleen, draining lymph nodes and cancer involved portion of blood vessels (distal pancreatosplenectomy-Posterior RAMPS, with celiac axis resection DP - CAR) and hepatic artery reconstruction. Artery was reconstructed with an artificial graft. (Image 1) This is performed only in highly experienced centers of excellence. Patient did have a long stay, share of some complications and recovered. He was again started on chemotherapy. He is currently doing well without any recurrence 1 year after diagnosis.

Case 2

63 year old gentleman presented to us in frank sepsis with jaundice. After quick initial investigations and treatment, a stent was placed to reduce the jaundice & sepsis. CT scan showed pancreatic tumorw in the head of pancreas involving portal vein partially (borderline resectable). The cancer was proved on an EUS guided biopsy. Bilirubin settled over next 2 weeks and patient was operated wherein a Whipple procedure with portal vein resection was done. Vein was reconstructed with an artificial graft. (Image 2) Patient recovered well over next 2-3 weeks and is currently awaiting chemotherapy.

These 2 cases exemplify pancreatic cancer in 2 separate locations, involving different set of vasculature, needing 2 different aggressive surgery-chemotherapy approach; though both are borderline resectable cancers. They also show that such patients can be successfully treated following the protocols set up by Centre’s of excellence worldwide in pancreatic surgery. These patients as mentioned before have a long recovery process involving various minor or major complications, prolonged hospital stay and unpredictable expenses. All such patients invariably need postoperative chemotherapy.