At the time of diagnosis, only about 20% of pancreatic ductal adenocarcinomas appear to be amenable of potentially curative surgical resection.

As seen in the diagnostic work-up and staging section, a pancreatic ductal carcinoma is considered resectable when it doesn’t extend into superior mesenteric artery and/or celiac trunk, and when has not spread in other distant organs (especially liver and lung). Tumor extension into superior mesenteric vein/portal vein is no longer a contraindication to radical surgery, but pancreatic resections with synchronous venous resection are very complex operations associated with increased morbidity.  

Although recent advances of cross sectional imaging allow detailed evaluation of the pancreas, the accuracy of radiologic staging is not 100%. In some cases it may be even hard to stage pancreatic cancer accurately using imaging tests. Therefore, when there is a good chance the tumor can be completely removed, surgery is undertaken, and the surgical exploration still plays the key role for the finally assessment of resectability. Sometimes an unexpected locally advanced or a metastatic disease is found. In this case, the surgeon may continue the operation as a palliative procedure to relieve or prevent symptoms.

However, the anatomy of the tumor is not the whole story. Other patient-related factors are equally as important to the decision-making process. Foremost among these include comorbidities and functional status. Comorbidities refer to other diseases that the patient may suffer from, such as heart disease or diabetes. Functional status refers to nutritional status, the ability to go through a major surgery, and to function independently after the operation. So assessment of resectability requires a complex evaluation of tumor anatomy, age, comorbidities, functional status and the results of a blood test (Ca 19.9) to determine the risk-benefit profile of surgery. 

In some cases, neoadjuvant therapy may be advised. Neoadjuvant therapy is medical therapy (chemo or chemo-radiotherapy) administered in resectable or borderline resectable disesase prior to the operation. The rationale for neoadjuvant therapy in pancreatic cancer is multifold. Preoperative therapy may theoretically sterilize peripheral extent of tumor infiltration, decrease tumor volume, and regional nodal disease. Furthermore, patients who receive neoadjuvant therapy are more likely to complete their full course of therapy compared to patients given post-operative chemotherapy. Additionally, neoadjuvant therapy administered to undissected, well-oxygenated tissue may maximize any cytotoxic benefit gained from treatment. Lastly, and perhaps most importantly, patients who exhibit disease progression during their neoadjuvant therapy self-select themselves as poor responders who are least likely to gain benefit from resection and may forego the morbidity of pancreatic resection. Results of studies evaluating the role of neoadjuvant therapy have shown promising results, despite large randomized trials are still lacking.

Formal surgical resections for pancreatic ductal adenocarcinoma include pancreaticoduodenectomy and left pancreatectomy with splenectomy. The goal of surgical resection is a complete tumor clearance, without leaving behind cancer residual. This concept is known as R0 surgery (without residual disease). Furthermore, formal pancreatic resections for cancer include regional lymphadenectomy. The role of extended lymph node dissection is controversial and does not seem to be beneficial. After resection, intraoperative frozen rection of the pancreatic resection margin is performed to rule out microscopic disease residual (R1) in the pancreatic remnant. Extension of the resection, up to total pancreatectomy with splenectomy may be necessary when the resection margin is positive for tumor cells.

The resection specimen is examined by the Pathologist. Histological examination confirms the diagnosis and assigns the pathologic tumor stage (according to the TNM system, AJCC, www.cancerstaging.org). Although not formally part of the TNM system, other histologic features are of paramount importance. The grade of the cancer (how abnormal the cells look under the microscope) is listed on a scale from G1 to G4, with G1 cancers looking the most like normal cells and having the best outlook. As seen, another important factor is the tumor clearance, whether or not all of the tumor is removed. This is listed on a scale from R0 (where all visible and microscopic tumor was removed) to R2 (where some visible tumor could not be removed). Furthermore, lymph nodes are analyzed to look for cancer involvement (lymph node status). The ratio between positive and total number of lymph nodes harvested (lymph node ratio) has been shown to be of prognostic relevance.

Patients are given chemotherapy or chemo-radiotheraphy after the cancer has been surgically removed to try to eliminate any cancer cells that have been left behind. This type of treatment is called adjuvant treatment, and lowers the chance that the cancer will recur. 

Patients who underwent a potentially curative pancreatic resection will be enrolled in an active surveillance protocol, consisting of a detailed clinical examination, cross-sectional imaging, and serum Ca 19.9 measurement.