Due to the anatomy and characteristics of the pancreas, it is quite common for cancer patients to get diagnosed when cancer is already considered unresectable, either because it has already metastasized or because it has spread and “invaded” large adjacent veins (portal vein and superior mesenteric vein) and arteries (hepatic, celiac, and superior mesenteric artery). Patients who belong to this category are considered to have unresectable cancer. However, the critical yet positive aspect of all these cases is that this type of cancer may be “locally advanced” but has not yet metastasized. The prognosis of patients with unresectable pancreatic cancer is dismal, as the median survival is 6-9 months. On the other hand, the prognosis of patients who have undergone radical surgery is significantly better, with a median survival rate that may reach up to 25-30% for three years. Having the possibility to move forward with a radical resection of the tumor is important. Unfortunately, patients with portal vein or artery infiltration are considered to have inoperable cancer. As a result, they are bound to remain in the first category that is associated with poor prognosis and significantly reduced survival. Thus, thousands of patients worldwide die from non-metastatic pancreatic cancer, which is not resected successfully due to the lack of experience and expertise. 

Our team has been focused on the resection of such tumors (i.e., removing the tumor along with the affected part of the artery or the vein) since 2012. We were the first in Greece to perform such surgical procedures on tumors previously considered unresectable. We were also the first to collect our findings from patients in Greece and publish the first series of 24 cases in which the involved portal or mesenteric vein was resected. Our article was published in the Journal of Pancreatic Cancer in September 2019 (https://www.liebertpub.com/doi/10.1089/pancan.2019.0013). Our approach resulted in an almost fourfold increase in patients’ survival compared to the survival rate of patients who did not undergo surgical intervention as their tumor was initially considered unresectable. Now we have also advanced in the resection of involved/affected arteries. We were the first to perform the Appleby procedure (resection of the involved celiac artery or celiac axis) in Greece. Further details on this surgery were published in our article at the International Journal of Surgery in October 2020 (https://doi.org/10.1016/j.ijscr.2020.09.194).

The conversion of pancreatic cancer from an initially unresectable state to a resectable one requires a dedicated and highly experienced team of surgeons that performs such procedures frequently and has relevant credentials. Such credentials include 

1. scientific publications in reputable scientific journals that have gone thorough checks and reviews and are held in high regard by internationally renowned pancreatic surgeons, and 
2. testimonials of patients who have been living for years after the resection of tumors that were generally considered “unresectable.”

A patient with locally advanced pancreatic cancer may move forward with radical resection after receiving chemotherapy preoperatively. Radiation treatment may also be administered. During chemotherapy, the patient’s clinical picture, the gradual decrease of the CA 19-9 tumor marker as well as the potential shrinkage of the tumor on the CT scan are carefully monitored. It should be noted that tumor shrinkage is not always achieved but this is not our primary goal anyway. Surgeons may move forward with radical resection after the administration of chemotherapy and if tumor markers have significantly decreased. Unfortunately, this favorable progression, i.e., converting unresectable cancer to resectable cancer is not always the case. In fact, it only concerns one-third (⅓) of patients. On the other hand, this fraction of patients (30%) would not exist if the process above had not been carefully followed.