Abstract
Obviously, performing an R0 resection procedure in a patient with ductal pancreatic adenocarcinoma, in conjunction with adjuvant chemotherapy, will significantly prolong the patient's life. Insight into some aspects of resection and lymphadenectomy varies worldwide.
Above all, it is often said that adequate oncological radicality of the procedure is performed. This issue has been addressed and addressed by a number of surgeons over the past two decades, when resection procedures have become relatively safe for patients because perioperative lethality has been significantly reduced.
The radicality of the procedure is assessed primarily in relation to the extent of lymphadenectomy, including the eventual removal of surrounding tissue, including a part of the blood vessels. However, an increase in the percentage of resecibility in patients with ductal adenocarcinoma of the pancreas does not mean an increase in radicality.
There are several reasons why increased radicality is not currently monitored by increased survival in ductal pancreatic cancer and is mainly due to the biological nature of the tumor. Perineural spread has been demonstrated in this tumor.
Thus, tumor removal and lymphatic drainage in advanced pancreatic cancer cannot be clearly identified as radical. In 43-72% of the patients, malignant cells can be found in neural knitting, even in the UICC groups I and II.
The same category of problem fits the fact that N1 node negativity in ductal pancreatic cancer demonstrated by routine screening procedures does not mean N1-3 node negativity in at least 30% of operated operations. Neither tumor size up to 2 cm is a guarantee: in one third of the patients lymph node involvement is observed.
Indeed, by the RT - PTC method, micrometastases can be found in the liver in 13 of 17 radically operated patients. It is not the purpose of this consideration to assess the possibilities of standard or extended performance - see the article in this issue of the magazine.
The aim is to emphasize the importance of continuous staging of the disease. In accordance with other authors, I consider the determination of preoperative staging to be essential.
It is possible in addition to contrast CT endoscopic ultrasonography with thin needle aspiration biopsy - EUS with FNAB. It is on this basis that the multidisciplinary team should decide on a treatment strategy.
Accuracy of current imaging techniques (contrast CT examination, respectively endo-ultrasonographic examination) in the diagnosis of pancreatic cancer reaches 73-97% depending on the size of the tumor bed with a resecibility prediction of 83, resp. 91%. This results in the surgeon's occasional surprise caused by the more advanced disease that he finds only during surgery.
We are therefore talking about the importance of peroperative staging. The definitive staging of the disease is determined after the evaluation of the resect and nodules by the pathologist.
However, definitive staging is a prerequisite not only for the proper setting of adjuvant chemotherapy, but also for the estimation of life prospection. According to the prepared standard of care, its determination should be a precondition for discontinuing treatment at a surgical workplace and reporting costs to health care payers.
It is a condition of qualified handing over the patient to oncologists. We cannot agree with the opinion that these procedures should be performed in specialized workplaces where the issue of treatment of pancreatic diseases is consistently addressed, where resection is not a random procedure and where the indication for surgery is supported by preoperative staging, where postoperative staging is also determined. and definitive.
This is the only way to ensure the greatest benefit for patients and to maintain optimal treatment costs for these patients