A 58-year-old man with a 3-month history of painless jaundice and weight loss is found to have a 3 cm mass in the pancreatic head on imaging. Biopsy confirms adenocarcinoma. Which feature would best distinguish this tumor as resectable (borderline resectable) rather than locally advanced unresectable?

## Resectability Assessment in Pancreatic Cancer ### Resectability Classification **Key Point:** Pancreatic cancer resectability is determined by the degree and extent of vascular involvement. The NCCN and AHPBA/SSO/SSAT consensus defines three categories based on arterial and venous involvement: ### Resectability Criteria Table | Category | Arterial Involvement | Venous Involvement | Resectability Status | |----------|---------------------|-------------------|---------------------| | **Resectable** | No involvement | No involvement or involvement amenable to reconstruction | Resectable | | **Borderline Resectable** | <180° SMA/celiac encasement OR short-segment involvement | Portal/SMV involvement with reconstruction possible | Potentially resectable with neoadjuvant therapy | | **Locally Advanced Unresectable** | >180° SMA/celiac encasement OR abutment of aorta | Unreconstructible venous involvement | Unresectable | | **Metastatic** | Any distant metastases (liver, peritoneum, lung) | — | Unresectable | ### Vascular Involvement Hierarchy ```mermaid flowchart TD A[Pancreatic mass on imaging]:::outcome --> B{Vascular involvement?}:::decision B -->|None| C[Resectable]:::action B -->|SMA/celiac <180° or short SMV/PV| D[Borderline Resectable]:::action B -->|SMA/celiac >180° or aortic involvement| E[Locally Advanced Unresectable]:::urgent B -->|Distant metastases| F[Metastatic/Unresectable]:::urgent D --> G[Neoadjuvant chemotherapy + reassess]:::action E --> H[Palliative chemotherapy]:::action F --> H ``` ### Critical Distinction: SMA Encasement Angle **High-Yield:** The **180° rule** is the gold standard: - **<180° encasement** of SMA or celiac axis = **borderline resectable** (can be resected with vascular reconstruction) - **>180° encasement** of SMA or celiac axis = **locally advanced unresectable** (too extensive for safe resection) **Clinical Pearl:** Borderline resectable tumors benefit from neoadjuvant chemotherapy (gemcitabine + nab-paclitaxel or FOLFIRINOX) to downstage the tumor and improve R0 resection rates. Locally advanced unresectable tumors are treated with palliative chemotherapy alone. ### Why Metastases Disqualify Resection **Warning:** Distant metastases (liver, peritoneum, lung, ascites) render the tumor unresectable regardless of local vascular involvement. The goal shifts from curative resection to palliative systemic therapy.