What Makes a Pancreatic Cancer Resectable?

Advanced imaging technology has improved preoperative clinical staging so that “exploratory surgery” to determine resectability for known or suspected pancreatic or periampullary cancer is not necessary and should not be performed in 2018.1 Preoperative evaluation should include a detailed history and physical examination (including functional status), chest imaging, laboratory studies including tumor markers (CA19-9 and carcinoembryonic antigen [CEA] at present; an expanded list of biomarkers will be available soon), contrast-enhanced pancreas-protocol CT of the abdomen, and evaluation of comorbid conditions as indicated. CT allows for assessment of the tumor’s relationship to the superior mesenteric artery (SMA), the superior mesenteric vein (SMV) and SMV–portal vein confluence (SMV-PV), the celiac artery, and the hepatic artery. CT also defines any arterial or venous aberrations (e.g., replaced left or right hepatic artery, inferior mesenteric vein draining directly into the SMV, jejunal branch of the SMV draining anterior to the SMA) and highlights potential lymph node or extrapancreatic metastases. Clinicians can then accurately stage the patient on the basis of CT imaging: (1) resectable, (2) borderline resectable, (3) locally advanced (now to include type A and type B), and (4) metastatic (Table 1).2,3 These categories are necessary to allow for optimal multidisciplinary treatment sequencing both on and off of a clinical trial, as this article discusses. TABLE 1. Classification of Locally Advanced Pancreatic Adenocarcinoma Into Type A and B and Comparison With Definitions Used for Resectable and Borderline Resectable Disease TABLE 1.Classification of Locally Advanced Pancreatic Adenocarcinoma Into Type A and B and Comparison With Definitions Used for Resectable and Borderline Resectable Disease View larger version (433K) There is an evolving recognition that pancreatic cancer is a systemic disease at the time of diagnosis, even among patients with apparent localized disease.4 As a result, and supported by recent data demonstrating improved overall survival for patients who are treated with multimodality therapy as compared with surgery alone, greater attention has been focused on the optimal treatment sequencing of chemotherapy, chemoradiation, and surgery for patients with localized pancreatic cancer. Inherent in the decision to deliver all three modalities (or even just chemotherapy and surgery) to a patient with localized pancreatic cancer is the accurate identification of those who have potentially operable disease at the time of diagnosis.