Anatomic definitions of borderline resectable pancreatic cancer

Pancreatic cancer is the fourth leading cause of cancer death in the United States and surgery offers the only opportunity for cure for patients who develop this disease. Indeed, a negative margin resection is considered one of the strongest prognostic factors for long-term survival. Improvement in imaging capabilities, specifically triple-phase contrasted computed tomography (CT) scans, has allowed clinicians to more accurately determine a patient’s likelihood of undergoing a margin-negative resection preoperatively. Historically, patients with tumor involvement of the mesenteric vasculature were considered to have unresectable disease due to high rates of positive margins following surgery; such patients were treated instead with palliative chemotherapy or chemoradiation. However, more recent data have demonstrated improved overall survival following multimodality therapy that includes surgical resection. Contemporary use of neoadjuvant therapy may allow for a subsequent margin-negative operation and may also improve patient selection to minimize the use of surgery in patients with biologically unfavorable disease. The concept of "borderline resectable pancreatic cancer" (BRPC) has simultaneously emerged. This stage designation is used for tumors that are at high risk for a margin-positive resection when surgery is used as an initial treatment approach. In this chapter, we will discuss the importance of this clinical category, review the relevant anatomy, and summarize specific definitions of BRPC within the current literature.