Borderline Resectable and Locally Advanced Pancreatic Cancer

While for anatomically and borderline resectable (AR and BR) pancreatic adenocarcinoma (PDAC) surgery remains the mainstay of the multimodality treatment plan, the treatment of locally advanced (LA) PDAC remains more nuanced because not every patient is truly on a surgical pathway. LA PDAC encompasses a spectrum of presentations ranging from tumors which can be potentially downstaged to BR or AR following systemic chemotherapy to those which truly remain unresectable due to sustained arterial encasement or unreconstructible venous involvement. At MD Anderson Cancer Center, clinical staging for BR PDAC is built around our “A-B-C” system, which classifies clinical presentations by tumor anatomy (“A”), tumor biology (“B”), and patient condition and comorbidities (“C”). Induction (often colloquially called “neoadjuvant”) therapy putatively treats the micro-metastatic disease that is almost universal in PDAC cases and allows time for medical optimization of the patient while tumor biology declares itself. For patients who undergo resection, the quality-of-life and cancer-related goals include return to intended oncologic therapy, low/no-complication surgery, and margin-negative resection. For all patients presenting with BR and LA PDAC, multidisciplinary management is required.