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Dr Wolfgang, Dr Schulick, and Dr Cameron provide an extremely comprehensive chapter on the evaluation and treatment of patients with cancer of the periampullary region and specifically the pancreatic head. The multidisciplinary working group from Johns Hopkins Hospital has made numerous contributions to the field of pancreatic cancer biology as well as the clinical management of patients with this disease. As all of you know, over the past two to three decades, Dr Cameron has demonstrated how to surgically manage patients with pancreatic cancer to achieve optimal outcome. Importantly, there has been a tremendous advance in both the understanding of the molecular biology of pancreatic cancer as well as our ability to accurately image the pancreas and periampullary region prior to surgery. Advances in both computed tomography (CT) and magnetic resonance imaging (MRI) have allowed for accurate assessment of critically important tumor-vessel relationships. Such accurate assessment of the relevant anatomy is important for both pretreatment staging and for planning the technical steps in performing pancreaticoduodenectomy, especially if vascular resection and reconstruction may be indicated. Although very experienced surgeons such as the authors can accurately assess resectability at the time of laparotomy, the ability to preoperatively classify patients as resectable, borderline resectable or locally advanced allows for the appropriate triage of patients for optimal treatment sequencing (surgery first or after neoadjuvant therapy), the evaluation of patients for investigator-initiated and cooperative group clinical trials, and for the referral of patients to higher volume centers. Indeed, to the extent that outcome is improved for patients with localized disease at high-volume centers (by high-volume surgeons), patients will need to be accurately staged (CT imaging) and, when necessary, have biliary stents placed safely in order to facilitate referral to a specialty center. The ability to perform endoscopic ultrasound (EUS)–guided fine-needle aspiration (FNA) biopsy will prevent diagnostic uncertainty and allow for medical oncology consultation and multidisciplinary care.
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Fortunately, the last decade has witnessed the development of consensus for the CT staging of pancreatic cancer. In an attempt to clarify the anatomy of resectable, borderline resectable, and locally advanced disease, Varadhachary and colleagues from the University of Texas M.D. Anderson Cancer Center proposed an objectively defined, CT-based classification that distinguished borderline resectable from both resectable and locally advanced pancreatic cancer.1 The Varadhachary definitions considered venous abutment and encasement (without occlusion) to be resectable, in the absence of tumor extension to the celiac or superior mesenteric (SMA) arteries. However, this definition was developed for the conduct of clinical trials of neoadjuvant treatment sequencing and was not intended to support a surgery-first strategy for patients who may require vascular resection and reconstruction. The Varadhachary definitions also assumed the technical capability to resect and reconstruct the superior mesenteric-portal vein (SMPV) confluence when necessary and that the major determinant of margin status (R status) was the tumor-artery (celiac, hepatic, SMA) relationship (Table 61A-1). Katz and colleagues in 2008 reported 160 patients with borderline resectable disease (using the Varadhachary definition) and introduced three ...