A patient-centered, multidisciplinary approach to treating borderline resectable pancreatic adenocarcinoma

The cancer-related death rate for pancreatic ductal adenocarcinoma (PDAC) has shown little improvement over the past decade, and PDAC is expected to be the second leading cause of cancer-related deaths by 2030. This is partly because most patients with PDAC present with metastatic (40%) or locally advanced (40%) disease, and only a minority of patients (20%) present with resectable or borderline resectable (BR) PDAC and are considered potential candidates for pancreatectomy, the only curative treatment available. Borderline resectability is a unique category within pancreatic cancer staging that represents tumors that are technically resectable, with or without vascular resection and reconstruction, but that are at high risk of harboring occult metastases at the time of diagnosis or positive margins if pancreatectomy is performed de novo. It assesses multiple dimensions of resectability including anatomy, biology, and condition. A multidisciplinary approach is essential to optimize each dimension and improve outcomes among patients with BR pancreatic adenocarcinoma. Here, we outline the evolution of the pancreatic cancer staging system as it pertains to surgical resectability, describe the influence this staging system has had on treatment, and review the evidence that guides a multidisciplinary approach to workup, staging, and treatment of patients with BR PDAC.