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In patients with pancreatic cancer, surgery is the primary modality of treatment. Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients.Patients with unresectable disease are treated with chemotherapy and/or radiation therapy as a part of adjuvant or neoadjuvant therapy. Curative resection is not contraindicated in all patients with vascular invasion. Involvement of the portal or superior mesenteric vein can be resected and reconstructed with the help of splenic, saphenous or internal jugular veins. However, the involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection. Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications. The facts are discussed by the patient and surgical team before arriving at a well-informed decision. The method of surgical resection depends on the following features:

• Locally invasive characteristics of the neoplasm
• Size
• Location

Methods of curative resection options include:

• • Distal Pancreatectomy
• Total pancreatectomy
• Pancreaticoduodenectomy, where pylorus may or may not be spared on an individual basis

The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms:

• Patient selection is based on:
  • Resection margins
  • High probability of cure
  • Patient's age
  • Comorbidities

European Society for Medical Oncology (ESMO) has certain guidelines on the treatment of metastatic pancreatic cancer:

• Chemotherapy not preferred
• Gemcitabine is preferred over 5 FU
• Treatment is symptomatic with bypass surgery or stent placement for gastric outlet obstruction or obstructive jaundice

In case of locally advanced disease which is unresectable, the following methods of treatment are preferred: Microwave ablation Photodynamic therapy Irreversible electroporation Photodynamic therapy High-intensity focused ultrasound (HIFU) Iodine-125–cryosurgery Iodine-125 Stereotactic body radiation therapy (SBRT) Radiofrequency ablation (RFA)

CHEMOTHERAPY

Metastatic disease/ Advanced pancreatic cancer which is unresectable: The National Comprehensive Cancer Network (NCCN) has recommended guidelines for treatment in patients based on their performance status. In order to predict survival of patients in various stages of pancreatic cancer, the performance status of a patient is a major prognostic factor. Patients with poor prognostic factors have poor performance status. This includes- Metastatic disease Large tumor Severe weight loss In patients with locally advanced unresectable or metastatic disease with good performance status Preferred treatment: FOLFIRINOX In patients with locally advanced unresectable or metastatic disease with good performance status with intolerance to FOLFIRINOX Preferred treatment:Paclitaxel protein bound+ Gemcitabine In patients with locally advanced unresectable or metastatic disease with poor performance status Preferred treatment: Gemcitabine monotherapy In patients with locally advanced unresectable or metastatic disease with poor performance status refractory to Gemcitabine: Preferred treatment: Capecitabine or capecitabine+erlotinib One year survival of FOLFIRINOX (leucovorin+5-lfuorouracil [LV5-FU]+oxaliplatin+irinotecan)>Gemcitabine One year survival of Gemcitabine+ Erlotinib> Gemcitabine One year survival of Gemcitabine+ Capecitabine≥Gemcitabine One year survival of Gemcitabine+ nanoparticle albumin-bound (nab)-paclitaxel> Gemcitabine