Multimodality management of localized and borderline resectable pancreatic adenocarcinoma

Abstract

Adenocarcinoma of the pancreas continues to be a daunting clinical challenge, with approximately 42,000 deaths per year in the United States (Jemal et al. 2009). It is a disease characterized by its late presentation, rapid demise thereafter, and relatively ineffective systemic therapies. Despite this grim prognosis, appreciable progress has been made in the identification of patients with localized disease who may be candidates for potentially curative resections and in the understanding of the technical nuances and efficacy of aggressive surgical procedures. Following initial reports in the 1930s of successful resections for periampullary tumors, the technique known as the Whipple procedure, or pancreaticoduodenectomy, underwent several technical modifications and revisions (Brunschwig 1937; Halsted 1899; Whipple et al. 1935). With time also has come a better understanding of the considerable physiologic impact and sequelae of the procedure and its potential, albeit limited, for cure. The high in-hospital mortality rate during the first several decades after the development of the operation led some to propose that it be abandoned, with risks not sufficiently justified by the low overall survival rates (Crile 1970; Shapiro 1975). By the late 1980s and early 1990s, series from experienced centers indicated that an aggressive surgical approach to periampullary tumors, of which pancreatic cancer is the most common, was justified. Morbidity and mortality rates dramatically improved and median survival rates began to significantly exceed the expected survival times of nonoperative treatment options (Crist et al. 1987; Trede et al. 1990). Today, the overall five-year survival rate is 15-25% for patients who undergo resection, compared with 1-5% for those who do not receive cancer-directed treatment (Bilimoria et al. 2007; Alexakis et al. 2004). © 2011 Springer-Verlag Berlin Heidelberg.