Borderline resectable pancreatic cancer

Rigorous criteria are essential to define resectability of PDAC, which allows foraccurate pretreatment staging and planning stage-specific therapy. Tumors ofborderline resectability have emerged as a distinct subset, and these patients areat a high risk for margin positive resection. The intergroup criteria for BRPCincludes: (1) an interface between the tumor and SMV-PV ≥180° of the veincircumference; (2) short-segment occlusion of the SMV-PV with normal veinabove and below the obstruction amenable to resection and reconstruction;(3) short-segment interface of any degree between tumor and HA with normal artery proximal and distal to the interface amenable to arterial resection and reconstruction; and (4) interface between the tumor and SMA and/or CA measuring <180° of the circumference of the artery. Two multicytotoxic regimens approved for metastatic disease, 5-flurouracil with oxaliplatin and irinotecan (FOLFIRINOX) and gemcitabine with nab-paclitaxel (Gem-nabP), are incorporated in the preoperative management of BRPC in many centers although high-level evidence data on these regimens in the neoadjuvant setting are not yet available. Those with radiographic stability or regression and an improvement in serum tumor markers (CA19-9) may proceed to pancreatectomy and may require vascular resection and reconstruction. Prospective clinical trials with well-defined eligibility will help determine the treatment strategies. Additionally, prognostic and predictive biomarkers are urgently needed in therapy planning.