Resectable and Borderline Resectable Pancreatic Cancer
Staging Criteria and Role of Pancreaticoduodenectomy
American Joint Committee on Cancer (AJCC) tumor, node, metastases (TNM) staging for pancreatic cancer was revised in 2002 and is presented in Table 1.4 Based on this, stages 3 and 4 are considered unresectable. Resectability criteria include a clear fat plane around celiac and superior mesenteric arteries (SMA), a patent superior mesenteric vein (SMV) and portal vein, and no distant metastases. Patients are considered to have ‘borderline’ resectable cancer if the CT scan shows cuffing or abutment to a portion of the SMA or celiac axis, severe unilateral SMV or portal vein impingement, or gastroduodenal artery (GDA) encasement up to origin at hepatic artery. These distinctions can usually be made without a pre-operative laparoscopy or endoscopic ultrasound, although most patients, once prepared for a pancreaticoduodenectomy (Whipple procedure), do undergo intra-operative laparoscopy.An additional 20% to 40% of patients may be found to be unresectable due to a small volume of peritoneal or hepatic metastases not visualized by CT. In highvolume centers, the peri-operative mortality from pancreaticoduodenectomy is less than 2%. Even after a potentially curative resection most patients recur, and five-year survivals are rare. Important prognostic features include tumor size (<2cm), lymph node involvement, and histologic grade.2,5 Post-operative complications include anastomotic leaks, delayed gastric emptying, thrombosis, infection, and bleeding.