Surgical treatment and locoregional therapy of liver metastases from pancreatic ductal adenocarcinoma: review of current strategies.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancer, with a 5-year survival of 8-10%. Approximately 50% of cases present with metastases at time of diagnosis, with the liver representing the most common site. International guidelines recommend palliative chemotherapy for metastatic disease, yet several studies report prolonged survival after surgery or locoregional therapy in selected patients with both synchronous and metachronous liver metastases (LM).

Evidence acquisition: Despite the numerous attempts to define selection criteria of patients with LM from PDAC who would benefit most from surgery, evidence is contradictory. This article aims to describe underlying principles of paradigm shift in multimodal management of hepatic oligometastatic PDAC, providing a summary of the published series with respect to morbidity, mortality and survival outcomes.

Evidence synthesis: Upfront resection of both primary tumor and synchronous LM should be avoided, since it does not imply prolonged survival compared to that of patients with liver oligometastatic PDAC candidate to chemotherapy. Resection or radiofrequency ablation of metachronous liver lesions can be an option in case of small metastases amenable of minor resection. Management of liver oligometastatic PDAC after neoadjuvant therapy can be performed in case of good response to chemotherapy after accurate restaging. Yet, duration of neoadjuvant therapy or entity of biological response are some issue still undefined in this setting.

Conclusions: Ongoing trial may overcome limitations of retrospective studies, as well as molecular biology can help to better understand tumor behavior and tailor the surgical approach on cancer genetic signature.