What are the criteria for a patient to be considered a candidate for surgery for pancreatic cancer?

Criteria for Operable Pancreatic Cancer

Pancreatic cancer is considered operable when there is no distant metastatic disease, no arterial involvement (SMA, celiac axis, or common hepatic artery), and limited or reconstructable venous involvement, with the patient having adequate performance status to tolerate major surgery. 1

Classification System

Pancreatic ductal adenocarcinoma is classified into three categories based on vascular involvement when metastases are absent 1:

Resectable Disease (Operable)

• No arterial contact: No tumor contact with the superior mesenteric artery (SMA), celiac axis, or common hepatic artery 1
• Minimal venous involvement: Clear fat plane around the superior mesenteric vein (SMV) and portal vein (PV), or tumor contact <180° without vessel deformation 1
• No distant metastases: Absence of hepatic, peritoneal, or distant lymph node metastases 1, 2
• Represents only 15-20% of patients at diagnosis 1

Borderline Resectable (Conditionally Operable)

• Limited arterial contact: Tumor contact with SMA <180° without deformation 1
• Venous involvement: Tumor abutment (≥180°) or encasement (>180°) of SMV-PV, or venous occlusion with reconstructable vessel ends 1
• Short-segment hepatic artery involvement: Tumor contact with common hepatic artery without extension to celiac axis 1
• Critical distinction: These patients have high probability of R1 (positive margin) resection and should NOT undergo upfront surgery 1
• Neoadjuvant therapy required: These patients need chemotherapy ± radiation before surgery to improve R0 resection rates 2, 3

Locally Advanced/Unresectable (Not Operable)

• Arterial encasement: Tumor contact >180° with SMA or celiac axis, or any contact with abutment/deformation 1
• Unreconstructable venous involvement: SMV-PV occlusion without possibility of reconstruction 1
• Distant metastases: Any metastatic disease to liver, peritoneum, distant lymph nodes, or other organs 4

Essential Staging Workup

Imaging Requirements

• CT angiography with pancreatic protocol: Arterial phase (40-50 seconds) and portal venous phase (65-70 seconds) to assess vascular involvement 1
• Each vessel must be assessed individually: SMA, celiac axis, common hepatic artery, portal vein, and SMV 1
• MRI indications: Problem-solving for indeterminate hepatic lesions, cystic pancreatic neoplasms, or biliary anatomy evaluation 1
• CT/MRI limitations: High positive predictive value (>90%) for determining unresectability, but insufficient (<50%) for confirming resectability 1

Tissue Diagnosis

• EUS-guided biopsy: Provides complementary staging information and allows tissue sampling 1
• Not required before upfront surgery: In clearly resectable disease with classic imaging findings, biopsy can be deferred 1

Patient Selection Criteria

Performance and Physiologic Status

• Performance status: Must be adequate to tolerate major pancreatic surgery 1, 2
• Nutritional status: Requires assessment and optimization pre-operatively 1, 2
• Medical comorbidities: Must be evaluated, but advanced age alone is NOT a contraindication 1

Biological Considerations

• CA 19-9 response to neoadjuvant therapy: Critical predictor of resectability and survival in borderline/locally advanced disease 3
• Tumor response to systemic therapy: Patients showing favorable response have better outcomes after surgery 3, 5

Surgical Goals and Margins

Primary Objective

• R0 resection is mandatory: Negative margins (≥1 mm clearance from all margins) 1, 2
• Seven margins must be assessed: Anterior, posterior, medial/superior mesenteric groove, SMA margin, pancreatic transection, bile duct, and enteric 1, 2

Venous Resection Considerations

• SMV-PV resection is acceptable: Can be performed with reconstruction to achieve R0 resection 1
• Associated with worse outcomes: Lower R0 rates and poorer survival due to tumor aggressiveness 1
• Arterial resection is NOT recommended: Associated with increased morbidity and mortality 1

Critical Pitfalls to Avoid

Common Errors

• Operating on borderline resectable disease upfront: These patients require neoadjuvant therapy first, not immediate surgery 1
• Attempting surgery with arterial involvement: Any significant arterial contact (>180° or with deformation) predicts unresectability 1
• Ignoring biological factors: Anatomical resectability alone is insufficient; tumor biology and treatment response matter 3, 5
• Surgery for metastatic disease: Stage IV disease with distant metastases derives no survival benefit from primary tumor resection 4

Referral Considerations

• High-volume centers: Resection rates are 20% higher and mortality significantly lower at specialized centers 2
• Multidisciplinary evaluation: Mandatory discussion in expert multidisciplinary teams to define optimal treatment strategy 2