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Borderline Resectable Ca Pancreas

Resectability Status in Pancreatic Adenocarcinoma

(NCCN Guidelines Version 1.2022)

1. Resectable

  • Arterial:

    • No arterial tumor contact with the celiac axis (CA), superior mesenteric artery (SMA), or common hepatic artery (CHA).

  • Venous:

    • No tumor contact with the superior mesenteric vein (SMV) or portal vein (PV) or ≤180° contact without vein contour irregularity.

2. Borderline Resectable:

  • Arterial:

    • Pancreatic head/uncinate process:
      • Solid tumor contact with CHA without extension to CA or hepatic artery bifurcation, allowing safe resection and reconstruction.
      • Solid tumor contact with the SMA of ≤180°.
      • Solid tumor contact with variant arterial anatomy (e.g., accessory right hepatic artery) without significant impact on surgical planning.
    • Pancreatic body/tail:
      • Solid tumor contact with the CA of ≤180°.

  • Venous:

    • Solid tumor contact with SMV or PV >180° with suitable vessel proximal and distal to the site of involvement for resection and reconstruction.
    • Solid tumor contact with the inferior vena cava (IVC).

3. Locally Advanced:

  • Arterial:

    • Head/uncinate process:
      • Solid tumor contact >180° with the SMA or CA.
    • Pancreatic body/tail:
      • Solid tumor contact >180° with the SMA or CA.
      • Solid tumor contact with the CA and aortic involvement.

  • Venous:

    • Unreconstructible SMV/PV due to tumor involvement or occlusion.

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Definition of Borderline Resectable Tumors (NCCN Guidelines) [Sabiston]

  • Definition: Borderline resectable tumors are those that exhibit one or more of the following characteristics:

1. Venous Involvement

  • Solid tumor contact with SMV or portal vein:
    • >180 degrees contact or
    • ≤180 degrees contact with contour irregularity or thrombosis of the vein.
  • Condition: There must be suitable vessel proximal and distal to the site of involvement to allow for safe and complete resection and vein reconstruction.

2. Arterial Involvement

  • Hepatic Artery Involvement:
    • Solid tumor contact with the common hepatic artery (CHA), which may involve abutment or encasement, but without extension to the celiac axis or hepatic artery bifurcation, allowing for safe and complete resection and reconstruction.
  • SMA Involvement:
    • Solid tumor contact with the SMA of ≤180 degrees.

MCQ Example:

  1. 60-year-old patient with a 3 cm hypodense lesion in the body of the pancreas, contact with CA >180 degrees, but aorta and GDA are free. True statement:

    • A: Unresectable tumor, palliative chemo
    • B: Resectable tumor, upfront surgery
    • C: Borderline resectable tumor, neoadjuvant chemotherapy (Correct answer)
    • D: Borderline resectable, upfront surgery

    Explanation:

    • C: This tumor is borderline resectable due to >180-degree contact with the celiac artery. For borderline resectable tumors, the standard approach is neoadjuvant chemotherapy to downstage the tumor before considering surgery.
      • An Appleby procedure (distal pancreatectomy with en bloc celiac axis resection) may be performed later after NACT.
    • A: The tumor is not unresectable since it does not involve the aorta or major vessels that would preclude surgery.
    • B and D: Upfront surgery is not recommended for borderline resectable tumors. Neoadjuvant chemotherapy is first given to improve surgical outcomes.

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    NCCN guidelines Resectability Status Based on 6th Edition Blumgart

    Resectable

    • Arterial Involvement:
      • No arterial tumor contact with the Celiac Axis (CA), Superior Mesenteric Artery (SMA), or Common Hepatic Artery (CHA).
    • Venous Involvement:
      • No tumor contact with the Superior Mesenteric Vein (SMV) or Portal Vein (PV).
      • ≤ 180-degree contact without vein contour irregularity.

    Borderline Resectable

    Head/Uncinate Process:

    • Arterial Involvement:
      • Solid tumor contact with the SMA ≤180 degrees.
      • Solid tumor contact with the CA ≤180 degrees without extension to the aorta or bifurcation of the hepatic artery.
      • Presence of variant arterial anatomy (e.g., replaced right hepatic artery, replaced CHA, and the accessory artery). The degree of tumor contact should be noted as it may affect surgical planning.
    • Venous Involvement:
      • Solid tumor contact with the SMV or PV >180 degrees, contact ≤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 allowing safe and complete resection with reconstruction.
      • Solid tumor contact with the Inferior Vena Cava (IVC).

    Body/Tail:

    • Arterial Involvement:
      • Solid tumor contact with the CA ≤180 degrees.
      • Solid tumor contact with the CA >180 degrees without involvement of the aorta and with intact and uninvolved gastrocolic trunk.

    Unresectable

    • Distant metastasis (including non-regional lymph node metastasis).

    Head/Uncinate Process:

    • Arterial Involvement:
      • Solid tumor contact with the SMA >180 degrees.
      • Solid tumor contact with the CA >180 degrees.
      • Solid tumor contact with the first jejunal SMA branch.
    • Venous Involvement:
      • Unreconstructible SMV/PV due to tumor involvement or occlusion.
      • Contact with the most proximal draining jejunal branch into the SMV.

    Body/Tail:

    • Arterial Involvement:
      • Solid tumor contact of >180 degrees with the SMA or CA with aortic involvement.
    • Venous Involvement:
      • Unreconstructible SMV/PV due to tumor involvement or occlusion.

    MD Anderson Criteria for Borderline Resectable Pancreatic Cancer (BRPC)

    Type A - Anatomic Criteria

    • Refers to tumor-vessel involvement that makes resection technically challenging but still potentially feasible with vascular reconstruction.
    • Includes tumor contact with the following vessels:
      • Superior Mesenteric Artery (SMA): Involvement ≤ 180 degrees.
      • Celiac Axis (CA): Involvement ≤ 180 degrees.
      • Superior Mesenteric Vein (SMV) or Portal Vein (PV): Tumor contact with distortion, narrowing, or occlusion that can still be reconstructed.

    Type B - Findings Suggestive of Metastatic Disease

    • Clinical or radiographic findings that indicate the possibility of metastasis, but not confirmed.
    • Includes:
      • Indeterminate hepatic lesions.
      • Peritoneal thickening or nodules.
      • Enlarged regional lymph nodes that raise suspicion for metastatic disease but are not definitive.

    Type C - Comorbidity Criteria

    • Refers to patient comorbidities that increase the risk of morbidity or mortality with surgery.
    • Includes conditions such as:
      • Cardiovascular disease.
      • Pulmonary disease.
      • Any other significant comorbid conditions that would impact surgical outcomes, making the patient a high-risk candidate for resection.

    NCCN Pancreatic Adenocarcinoma Guidelines (Version 1.2013) Defining Resectability based 6th Edition BLG:

    Resectability Status

    Localized and Resectable

    • No distant metastasis.
    • No radiographic evidence of SMV (Superior Mesenteric Vein) or HPV (Hepatic Portal Vein) distortion.
    • Clear fat planes around Celiac Axis (CA), Hepatic Artery (HA), and Superior Mesenteric Artery (SMA).
    • No tumor abutment of SMA.

    Borderline Resectable

    • No distant metastasis.
    • Venous involvement of SMV or HPV with distortion or narrowing of the vein or occlusion of the vein, with suitable vessel proximal and distal for resection and replacement.
    • GA (Gastroduodenal Artery) encasement up to the HA with either short-segment encasement or direct abutment of the HA without extension to the CA.
    • Tumor abutment of SMA less than 180 degrees.

    Unresectable

    • Distant metastasis present.
    • Arterial involvement:
      • >180 degrees SMA encasement.
      • Any celiac abutment.
      • Aortic encasement or invasion.
    • Venous involvement:
      • IVC (Inferior Vena Cava) involvement.
      • SMV/HPV unconstructible due to involvement or occlusion.