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Current Treatment Options in Gastroenterology

, Volume 8, Issue 5, pp 377–384 | Cite as

Borderline resectable pancreatic cancer

  • Gauri R. Varadhachary
  • Eric P. Tamm
  • Christopher Crane
  • Douglas B. Evans
  • Robert A. Wolff
Article

Opinion statement

Rigorous criteria to define "borderline resectable" pancreatic cancer are required for appropriate patient accrual into clinical trials that examine the utility of chemotherapy and/or chemoradiation that will be delivered prior to pancreatic resection for exocrine cancer. At our institution, tumor abutment of less than or equal to 180 degrees (≤ 50% of the vessel circumference) of the superior mesenteric artery, short segment abutment or encasement (≥50% of the vessel circumference) of the common hepatic artery (typically at the gastroduodenal artery origin), or segmental venous occlusion are used to categorize a pancreatic tumor as borderline resectable. These patients are at a high risk for margin positive resection with initial surgery; therefore, we favor a treatment schema that incorporates preoperative (neoadjuvant) therapy with systemic chemotherapy and chemoradiation. Patients whose tumors show radiographic stability or regression that are often accompanied by an improvement in serum tumor markers are candidates for pancreaticoduodenectomy. A prospective multicenter clinical trial with well-defined eligibility criteria may help decide the best overall treatment strategy for these patients. Vascular resection and reconstruction may be required in patients with borderline resectable tumors, and surgery should be performed at centers with expertise in such complex pancreatic resections.

Keywords

Pancreatic Cancer Superior Mesenteric Artery National Comprehensive Cancer Network National Comprehensive Cancer Network Superior Mesenteric Vein 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References and Recommended Reading

  1. 1.
    Jemal A, Murray T, Ward E, et al.: Cancer statistics. CA Cancer J Clin 2005, 55: 10–30.PubMedCrossRefGoogle Scholar
  2. 2.
    Wolff RA, Abbruzzese JL, Evans DB, eds: Neoplasms of the exocrine pancreas. In Cancer Medicine, edn. 2. Edited by Bast Jr. RC, Kufe DW, Pollock RE, et al. Hemilton, Ontario: American Cancer Society and B.C. Decker, Inc.; 2003: 1585–1614.Google Scholar
  3. 3.
    Li D, Xie K, Wolff R, et al.: Pancreatic cancer. Lancet 2004, 363: 1049–1057.PubMedCrossRefGoogle Scholar
  4. 4.
    Saldinger PF, Reilly M, Reynolds K, et al.: Is CT angiography sufficient for prediction of resectability of periampullary neoplasms [discussion 238–239]? J Gastrointest Surg 2000, 4: 233–237.PubMedCrossRefGoogle Scholar
  5. 5.
    Tamm E, Charnsangavej C, Szklaruk J: Advanced 3-D imaging for the evaluation of pancreatic cancer with multidetector CT. Int J Gastrointest Cancer 2001, 30: 65–71.PubMedCrossRefGoogle Scholar
  6. 6.
    Faria SC, Tamm EP, Loyer EM, et al.: Diagnosis and staging of pancreatic tumors. Semin Roentgenol 2004, 39: 397–411. This paper discusses CT imaging criteria for staging pancreatic cancer.PubMedCrossRefGoogle Scholar
  7. 7.
    Kulig J, Popiela T, Zajac A, et al.: The value of imaging techniques in the staging of pancreatic cancer. Surg Endosc 2005, 19: 361–365.PubMedCrossRefGoogle Scholar
  8. 8.
    Pisters PW, Lee JE, Vauthey JN, et al.: Laparoscopy in the staging of pancreatic cancer. Br J Surg 2001, 88: 325–337.PubMedCrossRefGoogle Scholar
  9. 9.
    Schmidt J, Fraunhofer S, Fleisch M, et al.: Is peritoneal cytology a predictor of unresectability in pancreatic carcinoma? Hepatogastroenterology 2004, 51: 1827–1831.PubMedGoogle Scholar
  10. 10.
    Zhao ZW, He JY, Tan G, et al.: Laparoscopy and laparoscopic ultrasonography in judging the resectability of pancreatic head cancer. Hepatobiliary Pancreat Dis Int 2003, 2: 609–611.PubMedGoogle Scholar
  11. 11.
    Chen VK, Arguedas MR, Kilgore ML, et al.: A costminimization analysis of alternative strategies in diagnosing pancreatic cancer. Am J Gastroenterol 2004, 99: 2223–2234.PubMedCrossRefGoogle Scholar
  12. 12.
    Levy MJ, Wiersema MJ: Pancreatic neoplasms. Gastrointest Endosc Clin N Am 2005, 15: 117–142.PubMedCrossRefGoogle Scholar
  13. 13.
    Eloubeidi MA, Gress FG, Savides TJ, et al.: Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States. Gastrointest Endosc 2004, 60: 385–389.PubMedCrossRefGoogle Scholar
  14. 14.
    Raut CP, Grau AM, Staerkel GA, et al.: Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration in patients with presumed pancreatic cancer [discussion 127–128]. J Gastrointest Surg 2003, 7: 118–126.PubMedCrossRefGoogle Scholar
  15. 15.
    Greene FL, Page DL, Fleming ID, et al.: AJCC Cancer Staging Manual, edn 6. New York: Springer-Verlag; 2002.Google Scholar
  16. 16.
    Tseng JF, Raut CP, Lee JE, et al.: Pancreaticoduodenectomy with vascular resection: margin status and survival duration. J Gastrointest Surg 2004, 8: 935–950. This is the largest study to date on vascular resection at the time of pancreaticoduodenectomy and compares the outcome of patients who underwent vascular resection with patients who underwent standard pancreaticoduodenectomy.PubMedCrossRefGoogle Scholar
  17. 17.
    Jarufe NP, Coldham C, Mayer AD, et al.: Favourable prognostic factors in a large UK experience of adenocarcinoma of the head of the pancreas and periampullary region. Dig Surg 2004, 21: 202–209.PubMedCrossRefGoogle Scholar
  18. 18.
    Lim JE, Chien MW, Earle CC: Prognostic factors following curative resection for pancreatic adenocarcinoma: a population-based, linked database analysis of 396 patients. Ann Surg 2003, 237: 74–85.PubMedCrossRefGoogle Scholar
  19. 19.
    Neoptolemos JP, Stocken DD, Dunn JA, et al.: Influence of resection margins on survival for patients with pancreatic cancer treated by adjuvant chemoradiation and/or chemotherapy in the ESPAC-1 randomized controlled trial. Ann Surg 2001, 234: 758–768.PubMedCrossRefGoogle Scholar
  20. 20.
    Neoptolemos JP, Stocken DD, Friess H, et al.: A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med 2004, 350: 1200–1210.PubMedCrossRefGoogle Scholar
  21. 21.
    National Comprehensive Cancer Network (NCCN) Practice Guidelines for Pancreatic Cancer, 2004.Google Scholar
  22. 22.
    Loyer EM, David CL, Dubrow RA, et al.: Vascular involvement in pancreatic adenocarcinoma: reassessment by thin-section CT. Abdom Imaging 1996, 21: 202–206.PubMedCrossRefGoogle Scholar
  23. 23.
    Lu DS, Reber HA, Krasny RM, et al.: Local staging of pancreatic cancer: criteria for unresectability of major vessels as revealed by pancreatic-phase, thin-section helical CT. AJR Am J Roentgenol 1997, 168: 1439–1443.PubMedGoogle Scholar
  24. 24.
    White RR, Tyler DS: Neoadjuvant therapy for pancreatic cancer: the Duke experience. Surg Oncol Clin N Am 2004, 13: 675–684, ix-x.PubMedCrossRefGoogle Scholar
  25. 25.
    Spitz FR, Abbruzzese JL, Lee JE, et al.: Preoperative and postoperative chemoradiation strategies in patients treated with pancreaticoduodenectomy for adenocarcinoma of the pancreas. J Clin Oncol 1997, 15: 928–937.PubMedGoogle Scholar
  26. 26.
    Breslin TM, Hess KR, Harbison DB, et al.: Neoadjuvant chemoradiotherapy for adenocarcinoma of the pancreas: treatment variables and survival duration. Ann Surg Oncol 2001, 8: 123–132.PubMedCrossRefGoogle Scholar
  27. 27.
    Yeo CJ, Cameron JL, Lillemoe KD, et al.: Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients [discussion 731–733]. Ann Surg 1995, 221: 721–731.PubMedCrossRefGoogle Scholar
  28. 28.
    Millikan KW, Deziel DJ, Silverstein JC, et al.: Prognostic factors associated with resectable adenocarcinoma of the head of the pancreas [discussion 623–624]. Am Surg 1999, 65: 618–623.PubMedGoogle Scholar
  29. 29.
    Sohn TA, Yeo CJ, Cameron JL, et al.: Resected adenocarcinoma of the pancreas-616 patients results, bdoutcomes, and prognostic indicators. J Gastrointest Surg 2000, 4: 567–579.PubMedCrossRefGoogle Scholar
  30. 30.
    Benassai G, Mastrorilli M, Quatro G, et al.: Factors influencing survival after resection for ductal adenocarcinoma of the head of the pancreas. J Surg Oncol 2000, 73: 212–218.PubMedCrossRefGoogle Scholar
  31. 31.
    Kuhlmann KF, de Castro SM, Wesseling JG, et al.: Surgical treatment of pancreatic adenocarcinoma; actual survival and prognostic factors in 343 patients. Eur J Cancer 2004, 40: 549–558.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2005

Authors and Affiliations

  • Gauri R. Varadhachary
    • 1
  • Eric P. Tamm
  • Christopher Crane
  • Douglas B. Evans
  • Robert A. Wolff
  1. 1.Department of Gastrointestinal Medical OncologyM.D. Anderson Cancer CenterHoustonUSA

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