Role of extended surgery for pancreatic cancer: Critical review of the four major RCTs comparing standard and extended surgery

Abstract

Pancreatic ductal carcinoma is one of the most dismal malignancies in the gastrointestinal system. Despite the development of several adjuvant therapeutic options, surgical treatment is still the only procedure that can completely cure this disease. Since pancreatic cancer easily extends to the adjacent tissues or develops distant metastasis, there has been argument as to whether we should perform extended surgery in order to widely eradicate peripancreatic tissue. After the report from Japanese surgeons that showed a survival benefit of the extended surgery for the invasive ductal carcinoma of the pancreas in the late 1980s, many Japanese surgeons applied the extended surgery for pancreatic cancer. However, the major problems of these studies were the retrospective and non-randomized nature of the study design. Thereafter, randomized controlled trials (RCT) comparing a standard and extended resection for the pancreatic cancer have been conducted first in Europe, second and third in the USA, and, subsequently, fourth in Japan. Unexpectedly, the survival benefit of the aggressive surgery has been refuted in all of the four major RCTs. This fact implied to us that surgery alone is not enough and that another adjuvant therapeutic option is necessary in order to improve the patients' survival of pancreatic cancer. © 2011 Japanese Society of Hepato-Biliary-Pancreatic Surgery and Springer.