International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017

Abstract

This statement was developed to promote international consensus on the definition of borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC) which was adopted by the National Comprehensive Cancer Network (NCCN) in 2006, but which has changed yearly and become more complicated. Based on a symposium held during the 20th meeting of the International Association of Pancreatology (IAP) in Sendai, Japan, in 2016, the presenters sought consensus on issues related to BR-PDAC. We defined patients with BR-PDAC according to the three distinct dimensions: anatomical (A), biological (B), and conditional (C). Anatomic factors include tumor contact with the superior mesenteric artery and/or celiac artery of less than 180° without showing stenosis or deformity, tumor contact with the common hepatic artery without showing tumor contact with the proper hepatic artery and/or celiac artery, and tumor contact with the superior mesenteric vein and/or portal vein including bilateral narrowing or occlusion without extending beyond the inferior border of the duodenum. Biological factors include potentially resectable disease based on anatomic criteria but with clinical findings suspicious for (but unproven) distant metastases or regional lymph nodes metastases diagnosed by biopsy or positron emission tomography-computed tomography. This also includes a serum carbohydrate antigen (CA) 19-9 level more than 500 units/ml. Conditional factors include the patients with potentially resectable disease based on anatomic and biologic criteria and with Eastern Cooperative Oncology Group (ECOG) performance status of 2 or more. The definition of BR-PDAC requires one or more positive dimensions (e.g. A, B, C, AB, AC, BC or ABC). The present definition acknowledges that resectability is not just about the anatomic relationship between the tumor and vessels, but that biological and conditional dimensions are also important. The aim in presenting this consensus definition is also to highlight issues which remain controversial and require further research.

Short‐term outcomes after vascular resection for pancreatic tumors: Lessons learned from 72 cases from a single Brazilian Cancer Center

“…Although there is a report in which authors demonstrated worse survival for types III and IV vascular resections in pancreatic resections, our study did not show the same relationship with major complications, leading us to recommend resections of larger pancreatic lesions involving retroperitoneal vascular structures. The main limiting factor in this study appeared to be the possibility of vascular reconstruction and the possibility to obtain resection with negative margins, expanding the indications for resection of locally advanced borderline tumors . It is worth noting, however, that in our series more than half of the cases had types III and IV reconstructions, which may have led to worse than expected survival rates.…”

Outcome of Patients with Borderline Resectable Pancreatic Cancer in the Contemporary Era of Neoadjuvant Chemotherapy

“…6–13 Although some patients are treated with an aggressive surgery-first approach and adjuvant systemic therapies, a preoperative chemotherapy and/or chemoradiation approach is becoming more common for all patients with BRPC. 14 The pre-operative treatment approach for the treatment of patients with BRPC has many potential benefits including a higher likelihood of achieving an R0 resection and early treatment of systemic disease for undetected micrometastasis. 15–18 Furthermore, it allows evaluation of the aggressiveness of the disease resulting in a better selection of surgical candidates.…”

Impact of neoadjuvant therapy on postoperative outcomes after pancreaticoduodenectomy

“…Some patients with pancreatic cancer present with borderline resectable tumors. The most recent consensus definition of borderline resectable pancreatic cancer includes anatomical considerations (contact with <180 degrees of the superior mesenteric artery and/or celiac artery, short segment contact with the common hepatic artery, and contact or occlusion with the superior mesenteric vein‐portal vein confluence with adequate vein proximal and distal for reconstruction), high‐risk biologic features, and patient performance status . All of these factors make upfront surgery risky, and studies have shown that these patients benefit from neoadjuvant chemotherapy and radiation .…”