**10. Treatment**

#### **10.1. Surgical intervention**

Surgery offers the only possibility for long term survival, however the majority (>85%) of patients with pancreatic cancer will present with unresectable or metastatic disease [76]. Removal of all disease offers the patient the only chance of long-term survival. Those who undergo surgical resection have a disappointing ~20% 5-year survival. Over the years it has become clear that the indications for surgical intervention have been substantially widened. Typically, the current criteria dictates possible resection for tumors stage I-A to II-B [77]. There are no randomized trials that assess resectability criteria to guide surgical intervention. In the absence of controlled trials, the best recommendations emanate from consensus guidelines [40, 78, 79]. It is practical to classify pancreatic tumors into one of three categories following diagnostic imaging [77]:


the possibility of reconstruction [40, 77]. These patients should undergo surgical intervention at the discretion of highly specialized pancreatic cancer centers, undergo neoajuvant treatment, and/or enrollment in clinical trials.

**iii. Unresectable Tumors**: These are tumors in which distant or extensive lymph node metastatic disease has been identified. Involvement of vasculature beyond resection or malignant ascites are also considered contra-indications for resection (i.e. major venous thrombosis of the portal vein or SMA that extends for several centimeters or circumferential encasement of the SMA) [78]. Resectability is best determined preoperatively rather than intraoperatively. These patients are candidates for chemotherapeutic interventions and enrollment in clinical trials as well as palliative interventions depending on degree of the disease.

According to a consensus statement by the American Hepato-Pancreato-Biliary Association, tissue obtained via EUS guided FNA is only required prior to surgery if neoadjuvant chemo‐ radiation is indicated. However, if there is sufficient evidence for pancreatic adenocarcinoma based on history, physical exam, and diagnostic modalities; no tissue is required in good surgical candidates prior to surgical intervention [78].
