Optimizing Outcomes in Borderline Resectable PDAC: A Multimodal Approach

In borderline resectable PDAC, individualized neoadjuvant therapy, advanced surgical techniques, and precise response assessment can increase margin‑negative resections and extend survival.

Where earlier practice favored routine upfront resection, care is now shifting to tailored preoperative strategies for patients with vessel‑involving tumors and variable physiologic reserve. This approach recognizes heterogeneity in tumor-vessel relationships and host factors and frames subsequent decisions about neoadjuvant therapy and operative technique.

Contemporary neoadjuvant options include multi‑agent systemic regimens—most commonly modified FOLFIRINOX versus gemcitabine‑based combinations—with growing interest in total neoadjuvant therapy and selective neoadjuvant radiotherapy. These strategies can downstage disease, treat occult micrometastases, and biologically select patients who tolerate and benefit from resection.

After neoadjuvant therapy, operative principles prioritize an oncologic R0 resection with en bloc removal and restoration of venous continuity when required. Segmental venous resection with SMV–PV reconstruction is commonly used during pancreaticoduodenectomy; selective arterial approaches and complex reconstructions are reserved for experienced teams. Institutional volume, multidisciplinary planning, and realistic perioperative risk assessment remain essential to safe expansion of resection candidacy.

Response evaluation relies on multiphasic contrast‑enhanced CT or pancreas‑protocol MRI, supplemented selectively by PET and serial CA 19‑9 measurements. Radiographic shrinkage or decreased vessel abutment does not always indicate complete tumor sterilization; radiomics and circulating tumor DNA are promising adjuncts but remain investigational. No single test suffices—integrated trends across imaging and biomarkers best guide conversion‑to‑resection decisions.