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  • Review Article
  • Published:

Optimizing the outcomes of pancreatic cancer surgery

Nature Reviews Clinical Oncology volume 16, pages 11–26 (2019)Cite this article

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Abstract

Pancreatic cancer is likely to become the second most frequent cause of cancer-associated mortality within the next decade. Surgical resection with adjuvant systemic chemotherapy currently provides the only chance of long-term survival. However, only 10–20% of patients with pancreatic cancer are diagnosed with localized, surgically resectable disease. The majority of patients present with metastatic disease and are not candidates for surgery, while surgery remains underused even in those with resectable disease owing to historical concerns regarding safety and efficacy. However, advances made over the past decade in the safety and efficacy of surgery have resulted in perioperative mortality of around 3% and 5-year survival approaching 30% after resection and adjuvant chemotherapy. Furthermore, owing to advances in both surgical techniques and systemic chemotherapy, the indications for resection have been extended to include locally advanced tumours. Many aspects of pancreatic cancer surgery, such as the management of postoperative morbidities, sequencing of resection and systemic therapy, and use of neoadjuvant therapy followed by resection for tumours previously considered unresectable, are rapidly evolving. In this Review, we summarize the current status of and new developments in pancreatic cancer surgery, while highlighting the most important research questions for attempts to further optimize outcomes.

Key points

  • Surgical resection in combination with systemic chemotherapy offers the only hope for long-term survival or cure in patients with nonmetastatic pancreatic cancer.

  • Surgical resection and adjuvant multi-agent chemotherapy (gemcitabine plus capecitabine or modified FOLFIRINOX) is the standard of care in patients with resectable pancreatic cancer.

  • Both the safety and efficacy of pancreatic cancer surgery have improved considerably in the past decade, enabling perioperative mortality of around 3% and 5-year survival approaching 30–40% after resection and chemotherapy.

  • Important criteria for assessing the quality of pancreatic cancer surgery include perioperative morbidity and mortality, oncologically determined pancreatic resection, the proportion of patients in fact receiving and completing adjuvant therapy and — above all — long-term survival.

  • Relationships between hospital pancreatectomy volume and outcome quality have an important role in determining the success of pancreatic cancer surgery.

  • Owing to advances in both surgery and systemic chemotherapy, the indications for surgical resections have been extended from stage I and II to locally advanced, previously unresectable pancreatic cancer.

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Fig. 1: Important quality criteria for pancreatic cancer surgery and their inter-relationships.
Fig. 2: Anatomical resectability of pancreatic cancer.
Fig. 3: Resectable pancreatic cancer.
Fig. 4: Borderline resectable pancreatic cancer.
Fig. 5: Resection after neoadjuvant therapy for historically unresectable pancreatic cancer.
Fig. 6: Increasing survival in trials of resection and adjuvant therapy for pancreatic cancer.

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Authors and Affiliations

  1. Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany

    Oliver Strobel, John Neoptolemos & Markus W. Büchler

  2. Department of Medical Oncology and Internal Medicine VI, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany

    Dirk Jäger

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  1. Oliver Strobel
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  2. John Neoptolemos
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  3. Dirk Jäger
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  4. Markus W. Büchler
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O.S., J.N. and M.W.B. researched data for this article. All authors made a substantial contribution to discussions of content, writing the manuscript and reviewing and/or editing the manuscript before submission.

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Correspondence to Markus W. Büchler.

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Strobel, O., Neoptolemos, J., Jäger, D. et al. Optimizing the outcomes of pancreatic cancer surgery. Nat Rev Clin Oncol 16, 11–26 (2019). https://doi.org/10.1038/s41571-018-0112-1

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