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Current resectability criteria for pancreatic cancer
Posted in Lectures on 30 May 2019

Jacqueline van Laarhoven

The European average incidence level of pancreatic cancer varies but 12,1 per 100,000 people are diagnosed each year, with a variation in 5-year survival of 0.5% – 9%.

At the time of diagnosis, 20% of the patients have a locally resectable tumor, 40% have metastasis, and 40% of patients have a locally non resectable tumor. There are different consensus documents which determine the resectability of pancreatic cancer. The criteria in these consensus documents vary, and to date there is no one guideline that is used worldwide. The CNNC guidelines are the most widely used.

Tumors are resectable if there is no arterial tumor contact to the celiac axis, the superior mesenteric artery or the common hepatic artery; no tumor contact with the superior mesenteric vein or portal vein; or if there is < 180 degree contact without vein contour irregularity.

Borderline resectable pancreatic head tumors are defined by:

  • Solid tumor contact with the common hepatic artery with no extension to the celiac axis or hepatic artery bifurcation.
  • Solid tumor contact with the superior mesenteric artery of < 180 degrees.
  • Solid tumor contact with variant arterial anatomy, for example an accessory right hepatic artery or a replaced right hepatic artery.
  • Solid tumor contact with the superior mesenteric vein or portal vein of > 180 degrees, contact of < 180 degrees with contour irregularity of the vein or thrombosis of the vein but with suitable vessel proximal and distal to the site of involvement.
  • Solid tumor contact with the inferior vena cava.

The goal of surgical treatment of pancreatic carcinoma is the achievement of an R0 resection. The resection margin was proven to be one of the most important factors related to the prognostic outcome for patients resected for pancreatic cancer.

In 2017 a systematic review was performed on neoadjuvant therapy in pancreatic cancer. Of borderline resectable tumors, 4.9% showed a complete response on imaging or histopathological examination, 28% of these patients showed a partial response, 50% had a stable disease and 17% of these patients had progressive disease.

In the Netherlands, the PREOPANC trial has been completed, which investigates if preoperative chemoradiotherapy in addition to the standard treatment improves the overall survival of patients with resectable or borderline resectable pancreatic cancer. Preliminary results showed that preoperative chemoradiotherapy significantly improves the outcome in (borderline) resectable pancreatic cancer compared to immediate surgery.