Organ- or function-preservation surgery is recommended, but who is a candidate?

Abstract

With the continuing development of advanced technology and the progression of medicine, many injured organs in the human body can be managed by a surgical approach, regardless of whether they are trauma- or non-trauma (diseases or aging process)-related.1–3 Minimally invasive surgical (MIS) treatment becomes more and more popular, and MIS has been in place of many traditional surgical approaches for these injured organs in recent decades.2–4 Although life-saving is the most critical issue for any disease treatment, postoperative recovery and quality of life should always be of concerned.5 Therefore, many advanced technologies, such as regenerative medicine, organ transplantation, and three-dimension-printed custom-made prosthetic reconstructions, etc., are reported to effectively assist in maintaining the basic or alternative function of damaged organs and/or tissue. However, by contrast, if accurate and precise preoperative evaluation and an appropriate surgical plan are conducted, minimally traumatic sparing organ and establishment of the physiological and morphological function of damaged tissues and/or organs may minimize the risk of overtreatment and avoid the subsequent severe postoperative sequelae without the need for further investment in new technology.6 All contribute to the re-consideration of the old proverb “to do more and to lose more.”7 The recent publication in the October issue of the Journal of the Chinese Medical Association entitled “Pancreatic head sparing surgery for solid pseudopapillary tumor in patients with agenesis of the dorsal pancreas,” showed the feasibility and possible safety of using sparing surgery of the pancreatic head (pancreatic head sparing surgery [PHSS]) in the management of patients with agenesis of the dorsal pancreas (ADP) accompanied by a solid pseudopapillary tumor (SPT).8 The authors retrospectively enrolled three patients with ADP accompanied with SPT who were treated with PHSS, and the results showed all patients who were alive ranged from 22 months to 75 months, even though one patient could not be totally resected for her SPT.8 Additionally, the authors evaluated 28 patients with SPT without ADP, and the outcomes of these patients were also excellent with a 100% of 20-year overall survival (OS) rate.8 Then, based on the concept of preservation of pancreas function and/or avoidance of pancreatic insufficiency, the authors suggested that PHSS for SPT is a feasible and safe method, and they particularly emphasized its feasibility for SPT patients concomitant with ADP.8 The current article is interesting and worthy of further discussion. Although the current article focused on using PHSS for SPT in patients with ADP, only three patients were enrolled.8 Moreover, the follow-up period is relatively short with a median of 15.8 months, and nobody had a follow-up period greater than 10 years. Compared to a median of 72.8 months for SPT patients without ADP, the conclusion suggested that PHSS for SPT patients with ADP is feasible and justifiable, and this procedure could be recommended for this population. We think that the authors’ conclusion may be at risk of overstatement. Similar to many other slowly growing malignant tumors, cancers of the low malignant potential (LMP) or low-grade cancers, and extensive benign diseases,9–11 conservative treatment for organ-preservation or function-preservation strategy is often discussed.10,12 However, many uncertainties are still present, and all should be well informed. A comprehensive review and thorough discussion between physicians and patients, as well as their families, are recommended.10,12 For example, the principles should include oncologic risk, a good candidate, response rate (success rate after primary treatment), counseling, surveillance, and functional outcome.12 If any issue cannot follow the aforementioned principles, an unexpectedly worse outcome may occur. Therefore, the clinical characteristics of either SPT or ADP should be carefully interpreted. ADP is an extremely rare malformation caused by the absence of the dorsal pancreatic bund of the endoderm, but the clinical characteristics of ADP vary greatly, ranging from incidental findings to complications of diseases.13 Based on the exocrine and endocrine tissues of the pancreas, abdominal pain and diabetes mellitus are the most frequent clinical manifestations reflecting impairment of function.13 However, the risk of neoplasm and nonalcoholic chronic pancreatitis have been highlighted because one report showed 17% (9/53) of ADP were finally complicated by carcinoma.13 Pancreatic cancer is a well-known disease with the worst prognosis compared to other cancers.14 We don’t know whether the cancer risk that occurred in nearly one-fifth of ADP patients is acceptable by the authors’ concept, but we are very concerned with this risk. Recently, prophylactic surgery for certain types of cancer, such as breast and ovarian cancers, has been re-considered.15 Additionally, the whole genome sequence and precise medicine have appealed to the general population.16 All suggest that the estimated or accumulated risk of certain diseases or the general population should always be balanced between the risks and benefits of organ- or function-preservation treatment. SPT frequently presents a single LMP neoplasm in the body and tail of the pancreas, which neither invades the surrounding structure nor causes biliary obstruction and metastasis, contributing to a 97% of an excellent 5-year OS rate.17 All this may be a rationale for Dr. Shyr’s group to perform PHSS for SPT patients with/without ADP.8 However, the literature review showed that recurrence or metastasis may occur after primary neoplasm resection, although it is a clinical situation of late recurrence, and it often occurs 8 to 16 years after surgery.17 Since the median follow-up period of Dr. Shyr’s group was only 67.7 months (72.8 months in SPT patients without ADP and particularly short [25.8 months] in SPT patients with ADP),8 it may be inappropriate to claim that this PHSS could be recommended for SPT patients with ADP to avoid pancreatic insufficiency by the authors. Although we are concerned with Dr. Shyr’s recommendation about the use of PHSS in the management of SPT patients with ADP, there is no doubt that the excellent therapeutic outcomes of the SPT patients with/without ADP after PHSS were indeed worthy of applause. Similar to all rare diseases or rare clinical situations,18 it is hard to get a consensus on how manage this rare disease, due to the impossibility to obtain the data from a large sample size. However, we still emphasize the careful interpretation of data to minimize the risk of misjudgment.5,19,20 ACKNOWLEDGMENTS This article was supported by grants from the Taiwan Ministry of Science and Technology, Executive Yuan, Taiwan (MOST 110-2314-B-075-016-MY3 and MOST 111-2314-B-075-045) and Taipei Veterans General Hospital (V112C-154 and V112D64-001-MY2-1). The authors appreciate the support from Female Cancer Foundation, Taipei, Taiwan.

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