Surgery based on resectability status of pancreatic cancer: a narrative review

Currently, it is routine to determine the treatment plans for pancreatic ductal adenocarcinoma (PDAC) based on the resectability status, which is classified into: resectable (R), borderline resectable (BR), and unresectable (UR). In patients with R-PDAC, we have frequently encountered distant metastases only after laparotomy. In addition, early postoperative recurrence may be noted even after curative resection. To overcome these issues, preoperative treatment has been recommended to estimate the tumor aggressiveness and avoid unnecessary surgery. For BR disease, all clinical trials comparing upfront surgery with preoperative treatment have shown a better prognosis with the latter. For UR disease, especially with distant metastases, a previous multi-institutional retrospective study suggested that we should consider conversion surgery after at least 8 months of chemotherapy. However, the postoperative prognosis remains unsatisfactory. Appropriate regimens and durations of preoperative treatment for each respectability status have yet to be established. Other issues, such as the feasibility of arterial reconstruction and whether all metastatic lesions should be removed, remain to be addressed.