Surgical management of pancreatic cancer: The Mayo Clinic approach

Between 1981 and 1991, we performed 174 'curative' resections for histopathologically confirmed, and histologically reconfirmed, ductal cancer of the pancreas during a time period when we evaluated 2,558 patients with pancreatic cancer (27). Approximately 16% of these resections proved to have positive margins, either grossly or microscopically, usually in the uncinate region. Overall 5-year actuarial survival was 6.8%; excluding the 28 patients with positive margins increased the survival to 12%. This experience further demonstrates that although surgeons debate about different types of resection and adjuvant care, at presentation the vast majority of patients ultimately prove to have incurable disease despite having either resectable or unresectable tumors. Greater emphasis thus should concentrate on earlier diagnosis, neoadjuvant treatment protocols, and adjuvant systemic therapy to salvage patients with occult distant metastases. It is hoped that advances in imaging, serologic markers, and aggressive screening of patients at increased risk (i.e., chronic pancreatitis, familial pancreatitis, or familial pancreatic cancer) using molecular diagnostic techniques (such as k-ras or P53) will lead to the improvement in patient outcome.