Pancreatic Cancer Resectability After Neoadjuvant Treatment: An Imaging Challenge

Background: Assessing pancreatic ductal adenocarcinoma (PDAC) resectability after neoadjuvant therapy (NAT) remains a diagnostic challenge. Traditional computed tomography (CT) criteria often fail to distinguish viable tumor from fibrosis, necessitating a reassessment of imaging-based standards. Methods: A comprehensive literature review was conducted using PubMed, focusing on prospective and retrospective studies over the past 25 years that evaluated the role of CT and complementary imaging modalities (MRI, PET-CT) in predicting resectability post-NAT in non-metastatic PDAC. Studies with small sample sizes or case reports were excluded. Results: Across studies, conventional CT parameters-particularly >180° vascular encasement-showed a limited correlation with histologic invasion or surgical outcomes after NAT. Persistent vessel contact on CT often reflected fibrosis, rather than active tumor. Dynamic changes, such as regression in the tumor-vessel interface and vessel lumen restoration, correlated more accurately with R0 resection. Adjunct markers like CA 19-9 response and patient performance status further improved resectability prediction. Conclusions: CT-based resectability assessment after NAT should transition from static morphologic criteria to response-based interpretation. Multidisciplinary evaluation integrating radiologic, biochemical, and clinical findings is essential to guide surgical decision-making and improve patient outcomes.