Adénocarcinome du pancréas: Quelles tumeurs operer et quand ? [Pancreatic adenocarcinoma: What is the best time for surgery?]
Résumé
Pancreatic ductal adenocarcinoma (PDAC) is associated with a poor prognosis even if some progresses have been made in the standardization of the surgery and perioperative care. Survival is conditioned by clear margins or not and by the occurrence of postoperative complications that can hamper the start of adjuvant chemotherapy before 8 weeks. Non curative resection rates without clear margin remain high (70%), even in case of an initially resectable pancreatic cancer. Those poor results questions the role of the primary tumor resection strategy in case of potentially curable PDAC. Only a comprehensive radiologic evaluation showing no arterial or vein involvement without metastatic spread can classify a pancreatic cancer as potentially curable. The line between borderline and locally advanced PDAC is currently a matter of debate. For borderline tumors, a preoperative treatment should be systematically discussed because of the high rates of R1 resection. For locally advanced PDAC, an aggressive strategy must be encouraged to maximize chances to get clear margins. Currently, identifying patients with a locally advanced but potentially curable PDAC after aggressive treatment is the therapeutic challenge. The expertise of multidisciplinary teams is crucial in order to choose the best strategy of treatment. The aim of this minireview is to redefine the good timing and the place of surgery in the modern era of PDAC management by focusing on potentially curable or locally advanced but potentially curable tumours.