[Multimodality treatment of carcinoma of the pancreas]

Although surgical resection has been the mainstream treatment for carcinoma of the pancreas, the operative results have been so disappointing that most surgeons in western countries have given up performing the resectional procedure. On the contrary, Japanese surgeons have never abandoned their dream of surgical treatment as a cure for the disease. Therefore, more and more aggressive procedures have been performed. Our operative results have not so remarkably ameliorated, but we have become knowledgeable on the pathological features of the carcinoma and believe that the best procedure for carcinoma of the head of the pancreas is a pancreatoduodenectomy with extensive dissection of regional lymph nodes and retroperitoneal tissue, and that surgery itself can not cure the disease but multimodality treatment should be established. Two hundred cases with carcinoma of the pancreas in which cystadenocarcinoma and islet cell carcinoma were excluded, were encountered from 1969 to 1987 in our department. Of 200 cases, only 48 cases underwent resection. Resection was divided into curative and non-curative resection according to macroscopic findings and pathohistological examination of the resected specimen. In cases of curative resection group, the average survival period of cases which underwent multimodality treatment was much longer than that without any adjuvant treatment. However, in cases of noncurative resection group, average survival period of cases with multimodality treatment was almost the same as that without adjuvant therapy. Therefore, multimodality treatment should be applied for curatively resected cases in order to obtain better results. Radiation therapy, especially intraoperative radiation therapy is considered to be a promising alternative modality of extensive retroperitoneal dissection. Hepatic metastasis was found postoperatively in about 27 percent of the resected cases. It seems that this type of recurrence occurred by migration of malignant cells from the tumor into the portal vein due to operative manipulation during surgery. Therefore, intraoperative infusion of an anticancer agent through the portal vein is mandatory, and preoperative and postoperative adjuvant chemotherapy should be considered.