Criteria for Resectability of Pancreatic Mass
A pancreatic mass is considered resectable when there is no arterial contact with the superior mesenteric artery (SMA), celiac axis, or common hepatic artery, no distant metastases, and only minimal or reconstructable venous involvement (portal vein/superior mesenteric vein). 1
Classification Framework
Pancreatic ductal adenocarcinoma is classified into three distinct categories based on vascular involvement when metastases are absent 2:
Resectable Disease (15-20% of patients at diagnosis)
Arterial criteria:
- No tumor contact with the SMA, celiac axis, or common hepatic artery 2, 1
- Clear fat plane preserved around all major arteries 1
Venous criteria:
- No tumor contact with the superior mesenteric vein (SMV) or portal vein (PV), OR 2
- Contact with SMV/PV of less than 180° without vessel deformity or thrombosis 2
Distant disease:
- No evidence of metastatic disease 1
Patient factors:
Borderline Resectable Disease
This intermediate category requires neoadjuvant therapy before surgery, as upfront resection carries high risk of positive margins 2, 1:
Arterial criteria:
- Tumor contact with SMA involving <180° of vessel circumference without stenosis or deformity 3, 4, 5
- Tumor contact with common hepatic artery without involvement of proper hepatic artery or celiac axis 4
- Short-segment encasement of hepatic artery amenable to resection and reconstruction 3
Venous criteria:
- Tumor contact with SMV/PV of >180° or causing contour irregularity 4
- Short-segment venous occlusion with suitable vessels above and below for reconstruction 3, 4
- Bilateral narrowing or occlusion not extending beyond inferior border of duodenum 4
Biological factors (expanded criteria):
- CA 19-9 level >500 units/mL 4
- Suspicious but unproven distant metastases or regional lymph node involvement 4
Conditional factors:
- ECOG performance status ≥2 despite anatomically resectable disease 4
Locally Advanced/Unresectable Disease
Arterial criteria:
- Tumor contact with SMA or celiac axis >180° 2
- Any tumor contact with the aorta 1
- Unreconstructable arterial involvement 1
Venous criteria:
- Unreconstructable SMV/PV occlusion 1
Critical Assessment Points
Each major vessel must be evaluated individually 2:
- Superior mesenteric artery
- Celiac axis
- Common hepatic artery
- Portal vein
- Superior mesenteric vein
Imaging modalities:
- CT angiography with pancreatic protocol is the primary staging tool 1
- MRI for problem-solving indeterminate hepatic lesions or cystic lesions 1
- EUS-guided biopsy provides tissue diagnosis and complementary staging 2, 1
Important caveat: CT/MRI have >90% positive predictive value for unresectability but <50% positive predictive value for resectability, meaning imaging can reliably rule out resection but cannot definitively confirm it 2
Surgical Goals and Margin Assessment
The primary objective is R0 resection (negative margins ≥1 mm) 2, 1, 6:
Seven margins must be assessed 1, 6:
- Anterior surface
- Posterior surface
- Medial/superior mesenteric groove
- Superior mesenteric artery margin
- Pancreatic transection margin
- Bile duct margin
- Enteric margin
Venous resection considerations:
- SMV/PV resection with reconstruction is acceptable to achieve R0 resection 2, 1
- However, venous resection is associated with lower R0 rates and worse survival due to inherent tumor aggressiveness 2
Arterial resection:
- Not recommended due to increased morbidity and mortality 2
Critical Pitfalls to Avoid
Do not operate on borderline resectable disease upfront 1:
- These patients have high probability of R1 resection 2
- Neoadjuvant therapy should be administered first 1, 3, 7
Do not attempt resection with significant arterial involvement 1:
- Arterial contact >180° predicts unresectability 2
- Associated with prohibitive morbidity and mortality 2