Treating Borderline Resectable Pancreatic Cancer

Abstract and Introduction

Abstract

The cancer-related death rate for pancreatic ductal adenocarcinoma (PDAC) has shown little improvement over the past decade, and PDAC is expected to be the second leading cause of cancer-related deaths by 2030. This is partly because most patients with PDAC present with metastatic (40%) or locally advanced (40%) disease, and only a minority of patients (20%) present with resectable or borderline resectable (BR) PDAC and are considered potential candidates for pancreatectomy, the only curative treatment available. Borderline resectability is a unique category within pancreatic cancer staging that represents tumors that are technically resectable, with or without vascular resection and reconstruction, but that are at high risk of harboring occult metastases at the time of diagnosis or positive margins if pancreatectomy is performed de novo. It assesses multiple dimensions of resectability including anatomy, biology, and condition. A multidisciplinary approach is essential to optimize each dimension and improve outcomes among patients with BR pancreatic adenocarcinoma. Here, we outline the evolution of the pancreatic cancer staging system as it pertains to surgical resectability, describe the influence this staging system has had on treatment, and review the evidence that guides a multidisciplinary approach to workup, staging, and treatment of patients with BR PDAC.

Introduction

Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related deaths in the United States but accounts for only 3% of new cancer diagnoses.^[1] Although the cancer-related death rate for many other solid organ malignancies has declined, the cancer-related death rate for PDAC has not shown similar improvement over the past decade, and PDAC is expected to be the second leading cause of cancer-related deaths by 2030.^[2] This is partly because most patients with PDAC present with metastatic (40%) or locally advanced (40%) disease.^[3] A minority of patients (20%) present with resectable or borderline resectable (BR) PDAC and are considered potential candidates for pancreatectomy, the only curative treatment available. Here, we outline the evolution of the pancreatic cancer staging system as it pertains to surgical resectability, describe the influence this staging system has had on treatment, and review the evidence that guides a multidisciplinary approach to workup, staging, and treatment of patients with BR PDAC.

Table 1. Anatomic definitions based on TVI of resectable, BR, and locally advanced PDAC as proposed by the AHPBA/SSAT/SSO, the Alliance Group, The University of Texas MDACC, and the MCW
Vessel	Group definition	AHPBA/SSAT/SSO (13,14)	Alliance (15)	MDACC (9,14)	MCW (16)
CA	Resectable	Clear fat planes, no involvement	No extension	No extension	No evidence of TVI
BR	TVI <180° without stenosis or deformity	TVI <180°	TVI <180° without stenosis or deformity; periarterial stranding forming a convexity	TVI <180°
Locally advanced	TVI ≥180°	TVI ≥180°	TVI ≥180° and no technical option for reconstruction	Type A: TVI ≥180° but does not extend to aorta and amenable to reconstruction. Type B: TVI ≥180° with extension beyond bifurcation of PHA
SMA	Resectable	Clear fat planes, no involvement	No extension	No extension; normal fat plane between the tumor and the artery	No evidence of TVI
BR	TVI <180° without stenosis or deformity	TVI <180°	TVI <180° without stenosis or deformity; periarterial stranding forming a convexity against the vessel	TVI <180°
Locally advanced	TVI ≥180°	TVI ≥180°	TVI ≥180°	Type A: TVI ≥180° but <270°. Type B: ≥270°
CHA	Resectable	Clear fat planes, no involvement	No extension	No extension	No evidence of arterial abutment
BR	Short segment TVI <180° without tumor contact with the PHA; GDA TVI ≥180° with short segment TVI ≥180° at CHA without CA involvement	Short segment TVI (of any degree) amenable to resection and reconstruction	Short segment TVI of any degree that is amenable to reconstruction, typically at the GDA	TVI <180° or short segment TVI ≥180° without extension to CA or PHA
Locally advanced	Involvement not amenable to reconstruction	Non-reconstructible involvement	Encased and no technical option for reconstruction	Type A: TVI ≥180° with extension to CA and amenable to reconstruction. Type B: TVI ≥180° with extension beyond the PHA
SMV/PV	Resectable	No evidence of TVI, distortion, tumor thrombus, or venous encasement	TVI <180°, without occlusion	Patent	Tumor-induced narrowing of ≤50%
BR	TVI of any degree with or without occlusion and amenable to reconstruction	TVI ≥180° and/or short-segment occlusion of the SMV-PV amenable to reconstruction	TVI ≥180° with or without occlusion; amenable to reconstruction	Tumor-induced narrowing of >50% amenable to reconstruction
Locally advanced	Any non-reconstructible involvement or major venous thrombosis extending several centimeters	Any non-reconstructible involvement	Occluded and no technical option for reconstruction	Occlusion without obvious option for reconstruction

Table 1. Anatomic definitions based on TVI of resectable, BR, and locally advanced PDAC as proposed by the AHPBA/SSAT/SSO, the Alliance Group, The University of Texas MDACC, and the MCW

Vessel

Group definition

AHPBA/SSAT/SSO (13,14)

Alliance (15)

MDACC (9,14)

MCW (16)

Resectable

Clear fat planes, no involvement

No extension

No evidence of TVI

TVI <180° without stenosis or deformity

TVI <180°

TVI <180° without stenosis or deformity; periarterial stranding forming a convexity

TVI <180°

Locally advanced

TVI ≥180°

TVI ≥180° and no technical option for reconstruction

Type A: TVI ≥180° but does not extend to aorta and amenable to reconstruction. Type B: TVI ≥180° with extension beyond bifurcation of PHA

SMA

Resectable

Clear fat planes, no involvement

No extension

No extension; normal fat plane between the tumor and the artery

No evidence of TVI

TVI <180° without stenosis or deformity

TVI <180°

TVI <180° without stenosis or deformity; periarterial stranding forming a convexity against the vessel

TVI <180°

Locally advanced

TVI ≥180°

Type A: TVI ≥180° but <270°. Type B: ≥270°

CHA

Resectable

Clear fat planes, no involvement

No extension

No evidence of arterial abutment

Short segment TVI <180° without tumor contact with the PHA; GDA TVI ≥180° with short segment TVI ≥180° at CHA without CA involvement

Short segment TVI (of any degree) amenable to resection and reconstruction

Short segment TVI of any degree that is amenable to reconstruction, typically at the GDA

TVI <180° or short segment TVI ≥180° without extension to CA or PHA

Locally advanced

Involvement not amenable to reconstruction

Non-reconstructible involvement

Encased and no technical option for reconstruction

Type A: TVI ≥180° with extension to CA and amenable to reconstruction. Type B: TVI ≥180° with extension beyond the PHA

SMV/PV

Resectable

No evidence of TVI, distortion, tumor thrombus, or venous encasement

TVI <180°, without occlusion

Patent

Tumor-induced narrowing of ≤50%

TVI of any degree with or without occlusion and amenable to reconstruction

TVI ≥180° and/or short-segment occlusion of the SMV-PV amenable to reconstruction

TVI ≥180° with or without occlusion; amenable to reconstruction

Tumor-induced narrowing of >50% amenable to reconstruction

Locally advanced

Any non-reconstructible involvement or major venous thrombosis extending several centimeters

Any non-reconstructible involvement

Occluded and no technical option for reconstruction

Occlusion without obvious option for reconstruction

A Patient-Centered, Multidisciplinary Approach to Treating Borderline Resectable Pancreatic Adenocarcinoma

Abstract and Introduction

Abstract

Introduction

Tables

References

Authors and Disclosures

Authors and Disclosures

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