Elsevier

Surgery

Volume 155, Issue 6, June 2014, Pages 977-988
Surgery

Consensus
Borderline resectable pancreatic cancer: A consensus statement by the International Study Group of Pancreatic Surgery (ISGPS)

https://doi.org/10.1016/j.surg.2014.02.001Get rights and content

Background

This position statement was developed to expedite a consensus on definition and treatment for borderline resectable pancreatic ductal adenocarcinoma (BRPC) that would have worldwide acceptability.

Methods

An international panel of pancreatic surgeons from well-established, high-volume centers collaborated on a literature review and development of consensus on issues related to borderline resectable pancreatic cancer.

Results

The International Study Group of Pancreatic Surgery (ISGPS) supports the National Comprehensive Cancer Network criteria for the definition of BRPC. Current evidence supports operative exploration and resection in the case of involvement of the mesentericoportal venous axis; in addition, a new classification of extrahepatic mesentericoportal venous resections is proposed by the ISGPS. Suspicion of arterial involvement should lead to exploration to confirm the imaging-based findings. Formal arterial resections are not recommended; however, in exceptional circumstances, individual therapeutic approaches may be evaluated under experimental protocols. The ISGPS endorses the recommendations for specimen examination and the definition of an R1 resection (tumor within 1 mm from the margin) used by the British Royal College of Pathologists. Standard preoperative diagnostics for BRPC may include: (1) serum levels of CA19-9, because CA19-9 levels predict survival in large retrospective series; and also (2) the modified Glasgow Prognostic Score and the neutrophil/lymphocyte ratio because of the prognostic relevance of the systemic inflammatory response. Various regimens of neoadjuvant therapy are recommended only in the setting of prospective trials at high-volume centers.

Conclusion

Current evidence justifies portomesenteric venous resection in patients with BRPC. Basic definitions were identified, that are currently lacking but that are needed to obtain further evidence and improvement for this important patient subgroup. A consensus for each topic is given.

Section snippets

Methods

A computerized search of the PubMed and Embase databases was done in February 2013, using the following terms: “pancreatic cancer,” “borderline resectable,” “extended resection,” “superior mesenteric vein,” “portal vein,” “celiac axis,” “superior mesenteric artery,” “common hepatic artery,” “irresectability,” “morbidity,” “mortality,” and “survival.” All levels of evidence were included and rated, according to the evidence level of individual studies defined by the recommendations of the Centre

Which patients have borderline resectable disease?

Several study groups have proposed a preoperative classification to identify patients with BRPC. Their goal was to optimize perioperative treatment and to minimize the risk of falsely categorizing a tumor as locally advanced.

The ISGPS suggests that preoperative evaluation of resectability be based on computed tomography (CT). The use of a pancreatic protocol is mandatory to assess clinical resectability. Such a protocol should achieve an optimal balance between visualization/resolution of

Summary

Current evidence supports portomesenteric resection in patients with BRPC. There is no good evidence that arterial resections during right-sided, proximal pancreatic resections are of benefit and should not be recommended. Basic definitions were suggested and are needed for obtaining further evidence and improvements in this important subgroup of patients with vessel involvement. A consensus for each topic is given that is supported by all members of the ISGPS. Multimodal therapy comprising

References (74)

  • A.D. Rhim et al.

    EMT and dissemination precede pancreatic tumor formation

    Cell

    (2012)
  • C.S. Verbeke et al.

    Redefining resection margin status in pancreatic cancer

    HPB (Oxford)

    (2009)
  • K.Y. Bilimoria et al.

    Effect of hospital volume on margin status after pancreaticoduodenectomy for cancer

    J Am Coll Surg

    (2008)
  • K.V. Menon et al.

    Impact of margin status on survival following pancreatoduodenectomy for cancer: the Leeds Pathology Protocol (LEEPP)

    HPB (Oxford)

    (2009)
  • N.B. Jamieson et al.

    The prognostic influence of resection margin clearance following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

    J Gastrointest Surg

    (2013)
  • M.H. Katz et al.

    Borderline resectable pancreatic cancer: the importance of this emerging stage of disease

    J Am Coll Surg

    (2008)
  • D.C. McMillan

    The systemic inflammation-based Glasgow Prognostic Score: a decade of experience in patients with cancer

    Cancer Treatment Rev

    (2013)
  • F.G. Uzunoglu et al.

    VEGFR-2, CXCR-2 and PAR-1 germline polymorphisms as predictors of survival in pancreatic carcinoma

    Ann Oncol

    (2013)
  • World Health Organization: Regional Office for Europe

    The European health report 2012: charting the way to well-being

    (2012)
  • National Cancer Insitute. SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations). Available from:...
  • S. Asada et al.

    Radical pancreatoduodenectomy and portal vein resection. Report of two successful cases with transplantation of portal vein

    Arch Surg

    (1963)
  • J.G. Fortner

    Regional resection of cancer of the pancreas: a new surgical approach

    Surgery

    (1973)
  • D.S. Lu et al.

    Two-phase helical CT for pancreatic tumors: pancreatic versus hepatic phase enhancement of tumor, pancreas, and vascular structures

    Radiology

    (1996)
  • J.G. Fletcher et al.

    Pancreatic malignancy: value of arterial, pancreatic, and hepatic phase imaging with multi-detector row CT

    Radiology

    (2003)
  • B.L. Appel et al.

    Current staging systems for pancreatic cancer

    Cancer J

    (2012)
  • G.R. Varadhachary et al.

    Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy

    Ann Surg Oncol

    (2006)
  • R.A. Abrams et al.

    Combined modality treatment of resectable and borderline resectable pancreas cancer: expert consensus statement

    Ann Surg Oncol

    (2009)
  • M.P. Callery et al.

    Pretreatment assessment of resectable and borderline resectable pancreatic cancer: expert consensus statement

    Ann Surg Oncol

    (2009)
  • D.B. Evans et al.

    Surgical treatment of resectable and borderline resectable pancreas cancer: expert consensus statement

    Ann Surg Oncol

    (2009)
  • National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Pancreatic Adenocarcinoma. Version...
  • H.P. Siriwardana et al.

    Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer

    Br J Surg

    (2006)
  • J.F. Tseng et al.

    Pancreaticoduodenectomy with vascular resection: margin status and survival duration

    J Gastrointest Surg

    (2004)
  • G.M. Fuhrman et al.

    Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group

    Ann Surg

    (1996)
  • L.E. Harrison et al.

    Isolated portal vein involvement in pancreatic adenocarcinoma. A contraindication for resection?

    Ann Surg

    (1996)
  • Y. Zhou et al.

    Pancreatectomy combined with superior mesenteric vein-portal vein resection for pancreatic cancer: a meta-analysis

    World J Surg

    (2012)
  • E.F. Yekebas et al.

    En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: perioperative outcome and long-term survival in 136 patients

    Ann Surg

    (2008)
  • Cited by (698)

    • Endoscopic Diagnosis of Extra-Luminal Cancers

      2024, Gastrointestinal Endoscopy Clinics of North America
    View all citing articles on Scopus

    M.B. and F.G.U. contributed equally to this work.

    View full text