Abstract
Surgery among patients with borderline resectable pancreatic cancer (BRPC) and venous disease has emerged as a viable strategy to achieve curative treatment. By definition, these patients are at increased risk of a positive resection margin, however, controversy exists with regards to necessity of radical surgery and optimum pathways with no consensus on definitive treatment. A surgery first approach is possible though outcomes vary but patients can have an efficient pathway to surgery, particularly if biliary drainage is avoided which limits overall complications. Neoadjuvant therapy (NAT) is emerging as a widely used strategy to improve oncological outcomes, including resection margin status. However, some patients progress on NAT whilst others suffer major complications whilst elderly patients are unlikely to be offered effective NAT limiting the widespread applicability of this therapy. In this article an overview of the entire pathway is presented along with assimilation of current best evidence to determine optimal routes to surgery for BRPC with venous involvement.
Highlights
Primum non nocere - first do no harm
Outcomes of established treatment can be viewed as marginal [2, 4] with disappointing disease free interval and median overall survival [3, 5] and as such there is a body of thinking that surgery and adjuvant chemotherapy representing the current gold standard treatment of borderline resectable pancreatic cancer (BRPC) [6], is essentially flawed
MRI [9] or PET [10] imaging are recommended to identify metastatic disease at presentation [6]
Summary
Primum non nocere - first do no harm. Attempts to achieve cure among patients with borderline resectable pancreatic cancer (BRPC) are certainly associated with harm [1,2,3]. It can be seen that risks of pancreatic fistula, the major determinant of morbidity and mortality after pancreatoduodenectomy are lower following surgery for PDAC than other indications [78] and, centralization and modern treatment algorithms are associated with much reduced rates of perioperative mortality [1] Among those patients with resectable PDAC the survival of patients with upfront surgery who do not receive adjuvant therapy appears similar to those receiving NAT who did not undergo surgery [19] i.e., for those patients that do not complete their treatment pathway there is no apparent survival advantage with either NAT or upfront surgery.
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