Borderline Resectable Pancreatic Adenocarcinoma

The consensus statement from the American HepatoPancreato-Biliary Association (AHPBA)9which is also endorsed by NCCN10and ESMO 11considered borderline resectable pancreatic adenocarcinoma to include the following:

1. No distant metastases.

2. Venous involvement of the superior mesenteric vein (SMV)/portal vein demonstrating tumour abutment with or without impingement and narrowing of the lumen, encasement of the SMV/portal vein but without encasement of the nearby arteries, or short segment venous occlusion resulting from either tumour thrombus or encasement, but with suitable vessel proximal and distal to the area of vessel involvement, allowing for safe resection and reconstruction.

3. Gastroduodenal artery encasement up to the hepatic artery with either short segment encasement or direct tumour abutment of the hepatic artery, but without extension to the celiac axis.

4. Tumour abutment of the superior mesenteric artery not to exceed >180 of the circumference of the vessel wall.

There is no clear consensus with regard to management of borderline resectable pancreatic adenocarcinoma. NCCN and ESMO guidelines consider neoadjuvant therapy as an acceptable option to upfront resection in patients with borderline resectable pancreatic cancer. There is however insufficient evidence to recommend specific neoadjuvant regimens. PEBC, Cancer Care Ontario (CCO), the Japan Pancreas Society (JPS) and the British Society of Gastroenterology, Pancreatic Society of Great Britain and Ireland and the Association of Upper Gastrointesinal Surgeons of Great Britain and Ireland (AUGIS) recommend participation in clinical trials where possible in this instance.

Recommendations for Borderline Resectable Pancreatic Adenocarcinoma

1. Neoadjuvant therapy can be considered in patients with borderline resectable pancreatic adenocarcinoma. There is insufficient evidence to recommend a specific regimen. Possible regimens for chemotherapy include FOLFIRINOX or gemcitabin-based combination chemotherapy. Subsequent chemoradiation can be considered after initial chemotherapy.

2. Participation in clinical trials recommended if available.