Elsevier

The Lancet Oncology

Volume 10, Issue 3, March 2009, Pages 287-293
The Lancet Oncology

Review
The role of surgery in the management of isolated metastases to the pancreas

https://doi.org/10.1016/S1470-2045(09)70065-8Get rights and content

Summary

Metastasectomy with curative intent has become standard practice for the management of some malignancies. Resection of isolated metastatic colorectal cancer, gastrointestinal stromal tumours, neuroendocrine cancers, renal-cell cancer and sarcoma is associated with longer survival or even cure. The strongest evidence in favour of metastasectomy exists for colorectal cancer, in which resection of limited metastatic disease in some patients is associated with 5-year survival rates of more than 50%.1, 2, 3 High incidence of the disease, predictable tumour biology, and development of successful chemotherapies have encouraged metastasectomy. Furthermore, improved safety of complex surgeries over the past several decades has lowered the threshold for more aggressive surgical intervention. Most literature on metastasectomy pertains to the resection of disease involving the liver, lung, and brain. However, metastasectomy has been described for almost every organ system, including the pancreas. In this Review, we discuss resection of isolated cancer metastases to the pancreas. Pancreatic metastasectomy is most often done through a formal pancreatic resection such as pancreaticoduodenectomy or distal pancreatectomy. Less often, pancreatic metastasectomy is done by enucleation or a pancreas sparing operation such as a central pancreatectomy.

Introduction

Metastatic disease to the pancreas is uncommon and accounts for less than 2% of all pancreatic malignancies. Most patients with metastatic disease are not candidates for resection since they have widespread systemic disease at the time of diagnosis. Although isolated pancreatic metastases are rare, high volume pancreatic surgery centres will see patients with metastatic disease that is amenable to resection. Moreover, the relatively favourable biology of some cancers that often metastasise to the pancreas, such as renal-cell cancer (figure), makes the recognition of surgically resectable disease important. For these patients, the role of pancreatic metastasectomy is not well defined.

So far, no prospective or case-controlled trials have compared the efficacy of pancreatic metastasectomy with non-operative management. Because of the uncommon presentation of isolated pancreatic metastasis and the tendency to resect these lesions, it is unlikely that such a study will be done. Therefore, the usefulness of pancreatic metastasectomy will be assessed by long-term survival in retrospective analyses. The largest study of pancreatic metastasectomy includes only 49 patients,4 and others include from 16 to 29 patients.5, 6, 7, 8 All have found that long-term survival can be achieved with pancreatic metastasectomy (table 1).4, 5, 6, 7, 8 Additionally, many case reports and results from smaller cohorts of patients undergoing pancreatic metastasectomy support the notion that the procedure improves survival in patients with isolated metastases to the pancreas.9, 10, 11

This Review aims to assess literature on pancreatic metastasectomy to provide guidelines for the surgical management of metastases to the pancreas. We review all studies with at least five patients who underwent pancreatic metastasectomy. Studies are retrospective single-institutional analyses and include a total of 243 patients. The breakdown of pathological diagnoses in this combined cohort is shown in table 2. An aggregate analysis was done on this cohort and is included in some parts of this Review. Findings from the aggregate analysis are designated as a pooled or aggregate result in the text in order to distinguish them from results listed in individual reports. Survival was analysed using Kaplan-Meier methods. Cox proportional hazard analysis was used to estimate relative differences between groups. Statistical significance was accepted at a p value less than 0·05. STATA statistical software (version 9.0SE, College Station, TX) was used for all statistical analyses. Three questions regarding pancreatic metastasectomy are addressed: How do patients with isolated pancreatic metastases typically present? Is pancreatic metastasectomy safe? Is pancreatic metastasectomy effective? Finally, we provide recommendations for selecting patients that might benefit from pancreatic metastasectomy.

Section snippets

How do patients with isolated pancreatic metastases typically present?

As with primary pancreatic cancer, early signs and symptoms of isolated pancreatic metastases are often non-specific and subtle. Isolated pancreatic metastases are often found with routine surveillance imaging for primary lesions or as an incidental finding on imaging done for an unrelated indication. The characteristic appearance of metastases to the pancreas on cross sectional-imaging has been described. Unlike pancreatic adenocarcinoma, secondary pancreatic cancers most often enhance on

Is pancreatic metastasectomy safe?

Pancreatic resection has been associated with a high rate of mortality and morbidity, and even the resection of localised primary pancreatic cancer has been questioned. However, many recent reports confirm that the mortality associated with pancreatic resection has declined over the past three decades. We previously reported a perioperative mortality rate of 2% and morbidity rate of 38% for patients undergoing pancreaticoduodenectomy for primary pancreatic pathology.25 These figures are similar

Is pancreatic metastasectomy effective?

The effectiveness of pancreatic metastasectomy is dependent on the tumour biology of the primary cancer. In most large studies, the best predictor for long-term survival is cancer type.4, 5, 7 Table 4 shows the distribution of cancers and associated survivals for the analysis of pooled data. Renal-cell carcinoma is associated with the best outcome, whereas lung cancer predicts the worst outcome. 80% of pancreatic metastasectomies result from four cancer-types: renal-cell cancer, colorectal

Selection of patients for pancreatic metastasectomy

Because of the possibility of substantial morbidity after pancreatic resection and the questionable benefit of metastasectomy in some patients, pancreatic metastasectomy should be offered only after a thoughtful and systematic selection process. Ideally, this process would involve a multidisciplinary team that includes a medical oncologist and an experienced pancreatic surgeon. Once the decision is made to proceed with resection, evidence suggests that the procedure should be done at a high

Conclusion

Although localised metastases to the pancreas are rare, pancreatic surgery referral centres will encounter these patients. Many case reports and small studies describe favourable outcomes for pancreatic metastasectomy. Renal-cell cancer, colorectal cancer, melanoma, and sarcoma are the most commonly resected metastases to the pancreas. The best outcome for pancreatic metastasectomy among these cancers is for renal-cell cancer. However, patients in all four groups might benefit from the

Search strategy and selection criteria

Information for this Review was obtained by a search of PubMed using the search terms “pancreas metastasis”, “pancreas metastasectomy”, “pancreas resection metastasis” and “pancreas resection non-pancreatic primary cancer”. We selected studies published in any language with at least five patients who underwent pancreatic metastasectomy. Only articles published before September, 2008, were included.

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