Surgical Treatment of Resectable and Borderline Resectable Pancreatic Cancer: Expert Consensus Statement by Evans et al.

Abstract

Developing a consensus regarding the role of palliative resection for patients with pancreatic adenocarcinoma first requires agreement on the definition of “palliative.” This alone may prove difficult because “surgical palliation” has varied definitions in the literature. Palliative procedures can refer to operations performed in the presence of metastatic disease, in patients with limited survival, and in patients undergoing incomplete resection. Researchers who have reported extensively on palliative operations suggest that a palliative procedure is one used with the primary intent of improving quality of life or relieving symptoms.28,29 The word “intent” suggests that a palliative procedure is one defined preoperatively—that is, establishing goals for the patient that are directed at alleviating specific symptoms. Current endoscopic and interventional methods for alleviating the symptoms of pancreatic cancer are quite effective. Endoscopic biliary and duodenal stenting require minimal hospital stay, have relatively low morbidity, and are becoming more durable. Interventional radiology techniques for biliary stenting and celiac plexus blockade likewise are quite effective. Operative bypass and celiac plexus blockade are durable approaches to the management of symptomatic pancreatic cancer, although they are more invasive. As a result of the effectiveness of these palliative approaches, consensus statement 4 is accurate. There is no role for palliative resection of pancreatic cancer in the setting of locally advanced or metastatic disease. In other words, pancreatic resection with the primary intent of symptom relief is not acceptable. Disagreement ensues with the use of alternative definitions of surgical palliation. Consensus statements 1 and 2 do not address palliation in the strict sense related to symptom relief. As the authors state in the consensus paper, all PDs are (or should be) undertaken with curative intent. The fact that some of these end up as margin-positive resections does not mean that post hoc, labeling them as palliative is appropriate. Nowhere is margin status a part of the strict definition of “palliative,” except perhaps the few occasions when debulking is appropriate for certain neoplasms. When the intent is curative but the resection result is margin positive, “incomplete” or “margin-positive resection” are terms that are more appropriate. Even these are ambiguous terms compared with the precise description defined by the R status (R1 or R2). To call this situation something other than that described by the R status invites confusion regarding the intent and outcome of the operation. Along similar lines, the opposite of “palliative” is not “curative.” The presence of margin positivity in a patient after PD should not immediately conjure images of a palliative procedure or imply palliation as the intent. In a different vein, series with long-term follow-up of margin-negative resections demonstrate recurrence in most patients, illustrating a noncurative outcome for most individuals. To call these operations “palliative” is a misuse of the term. Standard parlance does not use “palliative” in this fashion to describe recurrences after margin-negative resections in breast, colon, or skin or after other malignancies are found. To do so in the case of pancreatic cancer is likewise not a good idea. Margin status, like nodal status, is simply a predictor of worse disease-specific outcome. The power of this predictor is insufficient to discriminate between curative and noncurative resections. The margin status section above reviews this literature, which demonstrates similar survival between patients having R0 and R1 resections. Linking margin status, curability, and palliation, therefore, is illogical and further confuses the issue. Alas, though, we quibble about semantics, when in fact both sides are discussing the same issue. Although this may seem obvious to those intimately familiar with the field, for those who are not, the message lacks clarity. To ensure clear communications regarding this topic, specific definitions are appropriate. The use of “palliative” should be limited to interventions—operative or other—that have as their intent the relief of symptoms. Used in this fashion, the terms “palliative” and “PD” can never be coexistent, because as the authors previously stated, the goal of PD is cure. When a patient undergoes PD that results in a margin-positive resection, this is a R1 or R2 resection as clearly defined in the staging schema. No other definition is required. This will avoid confusion while providing specificity about the type of resection performed. In conclusion, recent studies address several technical issues related to PD, allowing refinements in the conduct of the operation. Increased complexity, in both judgment and technique, is the consequence of these improvements necessitating a higher degree of experience and expertise for a successful resection. If a patient is to derive the full benefit of these lessons, their assessment should come from an experienced pancreatic surgeon working in the context of a multidisciplinary group. Care in this context will allow patients to benefit from the full range of options and lessons outlined in this consensus conference.