Proposal for an Objective and Concrete Definition for Determining Anatomic Resectability in Pancreatic Cancer: The Concept of the "Suitable Target".

Abstract

Pancreatic ductal adenocarcinoma with extensive peripancreatic vessel involvement is classified as locally advanced pancreatic cancer (LAPC). For this group of patients, the current standard of care does not include considering a potentially curative oncologic resection. However, recent advances in multiagent chemotherapy and surgical techniques are challenging this paradigm. The current determination of anatomic resectability is vague and unreliable. Here, we propose a definition of local resectability based on pre- and intraoperative assessment. This anatomic definition of resectability assumes careful patient selection based on tumor biology and patient condition. The preoperative evaluation of vascular anatomy and tumor involvement is conducted using 3-dimensional rendering of the pancreas protocol CT. Identifying a disease-free arterial or venous segment above and below the tumor ("suitable target") is the single critical factor determining anatomic resectability. Intraoperative isolation of these target vessels confirms the feasibility of vascular reconstruction before resection. This approach, which focuses on identifying target vessels rather than circumferential involvement, offers a more straightforward and clinically relevant method for assessing surgical eligibility in patients with LAPC at centers of excellence. In summary, reconstructability-based on surgical expertise and guided by tumor biology-now defines the modern paradigm of resectability in LAPC.