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Extended distal pancreatectomy with thoracic wall resection after neoadjuvant FOLFIRINOX: Is there a limit of resection for pancreatic cancer after downstaging?
Ann Hepatobiliary Pancreat Surg 2020 Feb;24(1):90-6
Published online February 29, 2020;  https://doi.org/10.14701/ahbps.2020.24.1.90
Copyright © 2020 Korean Association of Hepato-Biliary-Pancreatic Surgery.

Tommaso Giuliani1, Maria López Rubio2, Eva Montalvá Oron2, Javier Maupoey Ibañez2, Andrea Boscá Robledo2, Cecilia López Valdivia3, Judith Pérez Rojas3, and Rafael Lopez Andujar2

1Department of General and Pancreatic Surgery, University of Verona, The Pancreas Institute, Verona Hospital Trust, Verona, Italy, Departments of 2HPB Surgery and Transplants, and 3Pathology, Hospital Universitario La Fe, Valencia, Spain
Received July 4, 2019; Revised July 18, 2019; Accepted July 25, 2019.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Abstract
Indications and outcomes of extended pancreatectomies have been recently appraised by the International Study Group for Pancreatic Surgery. However, no definitive conclusions have been drawn, particularly in the setting of neoadjuvant treatments. We present here a case of 53-year-old man diagnosed with a bulky adenocarcinoma of the tail of the pancreas and infiltrating the adjacent organs and the thoracic wall. The patient was sent to neoadjuvant chemotherapy and he underwent 12 cycles of FOLFIRINOX. Since a significant radiological response was observed after chemotherapy, the patient was scheduled for extended distal pancreatectomy with en bloc resection of the thoracic wall, in order to achieve a radical resection. The surgery is herein described with all technical details. The patient was discharged after an uneventful early post-operative course and subsequently readmitted for a late grade B post-operative pancreatic fistula, which was ultimately treated successfully. Pathology showed complete response. When performed in centers with ample experience in pancreatic surgery, extended pancreatic resections represent a viable curative option with acceptable surgical outcomes. In this setting, challenging tailored resections should be considered to achieve negative margins, particularly following maximized effective downstaging strategies.
Keywords : Pancreatic surgery; FOLFIRINOX; Extended pancreatectomy; Multivisceral resection