Pancreatic Cancer Resectability After Neoadjuvant Treatment: An Imaging Challenge

Area of Science:

• Oncology
• Radiology
• Surgical Oncology

Background:

• Pancreatic ductal adenocarcinoma (PDAC) resectability assessment post-neoadjuvant therapy (NAT) presents significant diagnostic challenges.
• Traditional computed tomography (CT) criteria struggle to differentiate viable tumor from post-treatment fibrosis.
• There is a critical need to re-evaluate current imaging standards for predicting surgical resectability in PDAC.

Purpose of the Study:

• To review and synthesize current evidence on imaging modalities for assessing PDAC resectability after NAT.
• To identify limitations of conventional CT criteria and explore advanced imaging techniques.
• To establish improved imaging-based guidelines for surgical decision-making in PDAC.

Main Methods:

• Comprehensive literature review of prospective and retrospective studies over 25 years using PubMed.
• Focus on CT, MRI, and PET-CT in predicting resectability for non-metastatic PDAC post-NAT.
• Exclusion of studies with small sample sizes or case reports to ensure robust findings.

Main Results:

• Conventional CT parameters, like >180° vascular encasement, showed limited correlation with actual tumor invasion or surgical outcomes.
• Persistent vessel contact on CT often represents fibrosis, not active tumor, after NAT.
• Dynamic CT changes (e.g., regression of tumor-vessel interface) and adjunct markers (CA 19-9, performance status) more accurately predict R0 resection.

Conclusions:

• Shift from static CT morphologic criteria to response-based interpretation for PDAC resectability assessment post-NAT.
• Multidisciplinary evaluation integrating radiologic, biochemical, and clinical data is crucial.
• Improved assessment strategies will enhance surgical decision-making and patient outcomes in PDAC management.