Maximilian Bockhorn1, Faik G Uzunoglu1, Mustapha Adham2, Clem Imrie3, Miroslav Milicevic4, Aken A Sandberg5, Horacio J Asbun6, Claudio Bassi7, Markus Büchler8, Richard M Charnley9, Kevin Conlon10, Laureano Fernandez Cruz11, Christos Dervenis12, Abe Fingerhutt13, Helmut Friess14, Dirk J Gouma15, Werner Hartwig8, Keith D Lillemoe16, Marco Montorsi17, John P Neoptolemos18, Shailesh V Shrikhande19, Kyoichi Takaori20, William Traverso21, Yogesh K Vashist1, Charles Vollmer22, Charles J Yeo23, Jakob R Izbicki24. 1. Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany. 2. Department of HPB Surgery, Hôpital Edouard Herriot, Lyon, France. 3. Academic Unit of Surgery, University of Glasgow, Glasgow, UK. 4. First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia. 5. Department of Surgery, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden. 6. Department of General Surgery, Mayo Clinic, Jacksonville, FL. 7. Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy. 8. Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany. 9. Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK. 10. Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland. 11. Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain. 12. First Department of Surgery, Agia Olga Hospital, Athens, Greece. 13. Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France. 14. Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany. 15. Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. 16. Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. 17. Department of General Surgery, Instituto Clinico Humanitas IRCCS, University of Milan, Milan, Italy. 18. Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK. 19. Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Centre, Mumbai, India. 20. Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan. 21. St. Luke's Clinic - Center For Pancreatic and Liver Diseases, Boise, ID. 22. Department of Gastrointestinal Surgery, Penn Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA. 23. Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA. 24. Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany. Electronic address: izbicki@uke.de.
Abstract
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.
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.
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