Overview

Resection has become an established part of the standard therapy for liver and lung metastases of several primary tumors (Fong et al, 1999; Quiros & Scott, 2008). Unlike liver and lung, the pancreas is an uncommon site of metastases. In autopsy series, 3% to 12% of patients with diffuse metastatic disease have pancreatic involvement (Showalter et al, 2008), and metastases account for only about 2% to 4% of malignant lesions in the pancreas (Showalter et al, 2008; Strobel et al, 2009). However, this number is increased up to 40% in patients with a pancreatic mass and a history of malignant disease (Roland & van Heerden, 1989; Z’Graggen et al, 1998).

Metastases to the pancreas may occur as isolated lesions or with additional extrapancreatic metastases that are technically resectable; isolated pancreatic metastases are very rare. Until recently the available data on resection for pancreatic metastases were based only on small series and multiple case reports. However, recent larger series and meta-analyses suggest that resection for pancreatic metastases is safe and associated with a favorable long-term outcome in appropriate patients (Reddy et al, 2008; Reddy & Wolfgang, 2009; Strobel et al, 2009; Tanis et al, 2009). This is best documented for metastastic renal cell carcinoma (RCC), the most frequent primary tumor of isolated pancreatic metastases (Sellner et al, 2006; Tanis et al, 2009). Based on these recent data, pancreatic resection can be recommended as part of an interdisciplinary treatment in metastatic disease to the pancreas.

This chapter summarizes the recent literature on surgery for pancreatic metastases and discusses the surgical approach, including diagnostic workup, patient selection, and technique of resection.

Results of Surgery for Pancreatic Metastases

Because isolated pancreatic metastases and metastases with localized, treatable extrapancreatic disease are uncommon, the results of pancreatic resection for metastases are not as well documented as for the liver or lung (Fong et al, 1999; Internullo et al, 2008). Until recently, the available literature was based only on smaller series and multiple case reports, which inherently tend to be biased toward the report of favorable results. However, in recent years, resection for metastases to the pancreas has been used more frequently, resulting in several larger series and, most recently, meta-analyses. This change occurred for several reasons. In the last decades, morbidity and mortality rates of pancreatic surgery decreased considerably, and pancreatic surgery can now be considered a safe procedure when performed by experienced surgeons (see Chapter 62A, Chapter 62B ). With the development of more effective drugs and tailored chemotherapy, the prognosis of metastatic disease has largely improved for several tumor entities. Also, with standardized follow-up programs after resection for cancer and with broader use of cross-sectional imaging, pancreatic metastases are more frequently detected at a resectable stage. Finally, the decision for resection of a pancreatic metastasis is more frequently made in an interdisciplinary setting, such as by tumor boards, which are established in most centers.