Borderline Resectable Pancreatic Cancer: Definitions, Management, and Role of Preoperative Therapy

Abstract

With recent advances in pancreatic imaging and surgical techniques, a distinct subset of pancreatic tumors is emerging that blurs the distinction between resectable and locally advanced disease: tumors of "borderline resectability." In our practice, patients with borderline-resectable pancreatic cancer include those whose tumors exhibit encasement of a short segment of the hepatic artery, without evidence of tumor extension to the celiac axis, that is amenable to resection and reconstruction; tumor abutment of the superior mesenteric artery involving <180 degrees of the circumference of the artery; or short-segment occlusion of the superior mesenteric vein, portal vein, or their confluence with a suitable option available for vascular reconstruction because the veins are normal above and below the area of tumor involvement. With currently available surgical techniques, patients with borderline-resectable pancreatic head cancer are at high risk for a margin-positive resection. Therefore, our approach to these patients is to use preoperative systemic therapy and local-regional chemoradiation to maximize the potential for an R0 resection and to avoid R2 resections. In our experience, patients with favorable responses to preoperative therapy (radiographical evidence of tumor regression and improvement in serum tumor marker levels) are the subset of patients who have the best chance for an R0 resection and a favorable long-term outcome.

Improving Survival of Pancreatic Cancer. What Have We Learnt?

“…After it was first described by Varadhachary [28] et al in 2006, there has been extensive research focusing on the best treatment for a subcategory of pancreatic cancer patients that sits on the distinction between resectable and locally advanced disease. The entity has been variously defined by various groups and surgical associations, but a consensus is lacking even to date and we are still in the process of defining an entity that was identified almost a decade ago [29].…”

Beyond the Whipple Operation: Radical Resections for Cancers of the Head of the Pancreas

“…Once imaging has been obtained, pancreatic cancer can be categorized into 3 groups: (1) resectable, (2) borderline resectable, and (3) locally-advanced [11]. Resectable cancers have no extension to the SMA, have a normal fat plane surrounding the SMA, have no extension to the celiac axis or common hepatic artery, and have possible abutment but patency of the SMV and PV.…”

“…These borderline resectable patients may become eligible for surgical intervention with downsizing of disease, but are not immediate candidates for surgical resection. Finally, locally-advanced pancreatic cancers have >180°encasement of the SMA, encasement of the celiac axis or common hepatic artery, or complete occlusion of the SMV/PV [11]. Patients with locally-advanced cancers are not candidates to undergo surgical resection [12].…”

Contemporary Management of Borderline Resectable and Locally Advanced Unresectable Pancreatic Cancer

“…Resectable disease comprises only 15% to 20% of patients at presentation. The vast majority of patients with PC present at advanced stages of disease, with approximately 50% of patients having metastatic disease [2] and an additional 25% to 35% of patients presenting with either borderline resectable pancreatic cancer (BRPC) or locally advanced unresectable pancreatic cancer (LAPC) [3].…”

“…BRPC is defined as tumor with limited involvement of the adjacent vascular structures where vascular reconstruction options are feasible [3]. There is no consensus in the surgical oncology community on the definition of what degree of vascular reconstruction should be considered resectable in the management of pancreatic cancer.…”