1. Borderline Resectable Pancreatic CarcinomaBY
AHMED M. BASHA
Senior Registirar
Surgical Oncology Unit

2. Background
Complete surgical resection is the only potentially curative modality of treatment for pancreatic cancer.
An initial assessment of resectability can usually be made based upon the preoperative triphasic contrast-enhanced CT scan of the pancreas.
. Local unresectability is usually (but not always) due to vascular invasion, particularly of the superior mesenteric artery (SMA).

4. Intraoperative Assessment of Resectability
Inaccurate
Incomplete gross resection provides no survival benefit compared to chemoradiation without surgery

6. Consensus-based NCCN guidelines define the following characteristics as indicating unresectability:
Head of pancreas lesions
Greater than 180 degrees SMA encasement, any celiac abutment
Unreconstructable SMV/portal vein occlusion
Aortic invasion or encasement
Body
SMA or celiac encasement greater than 180 degrees
Aortic invasion
Tail
For all sites
Distant metastases
Metastases to lymph nodes beyond the field of resection
SMV
SMA

7. Borderline resectable
definition is variable 
consensus based definition NCCN , AHPBA, and cosponsored by the Society of Surgical Oncology and the Society for Surgery of the Alimentary tract include the following :
No distant metastases.
Venous involvement.
Arterial involvement.
SMV
SMA

8. Borderline resectable
Venous involvement
of the SMV/portal vein demonstrating tumor abutment with or without 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 tumor thrombus or encasement, but with suitable vessel proximal and distal to the area of vessel involvement, allowing for safe resection and reconstruction

9. Borderline resectable
Arterial involvement
GDA encasement up to the hepatic artery with either short segment encasement or direct tumor abutment of the hepatic artery, without extension to the celiac axis.
Tumor abutment of the SMA not to exceed >180 degrees of the circumference of the vessel wall.

10. Treatment
At some institutions, these patients are treated with upfront surgical exploration and resection, if technically feasible.
However, at other centers, in an attempt to increase the likelihood of a margin-negative resection, such patients are treated initially with Neoadjuvant therapy (chemotherapy, chemoradiotherapy or both) followed by restaging and surgical reevaluation.

11. ALL the available data utilizing neoadjuvant therapy in patients with borderline resectable disease consist mainly of small single institution series and small phase II (uncontrolled) trials in which a mixture of patients with initially resectable, unresectable, and borderline resectable disease were enrolled

12. MD Anderson Trial
160 patients who were classified as borderline resectable
125 completed neoadjuvant therapy (induction chemotherapy in 82; chemoradiotherapy in 117) and were restaged

13. MD Anderson Trial
82 had potentially operative tumors, of whom 79 underwent an operation; 66 were resected, 62 with microscopically negative margins (38 % of the original cohort).
At a median follow-up of 27 months
Among the 66 patients who completed all therapy, the five-year survival was 36 %,
and 27 patients remained free of disease progression at last follow-up.

14. saph vein patch Rev saph vein graft divided CHA bile duct PV Spl A
Spl V
SMV
492495

15. A meta-analysis of phase II trials
suggest that in some cases where resectability is borderline on the basis of vascular involvement, Neoadjuvant chemotherapy, chemoradiotherapy, or a combined approach is feasible and may contribute to complete resection and long-term survival.
However, whether this approach is superior to upfront surgery followed by adjuvant therapy is not established.
Furthermore, the best regimen to use for neoadjuvant therapy in this setting is not established.

19. THANK YOU