Chinese experts establish new national standard for imaging assessment of pancreatic cancer resectability
New Chinese expert consensus standardizes resectability assessment for pancreatic cancer
image: This table clearly illustrates the key criteria for classifying pancreatic cancer into "resectable," "borderline resectable," and "locally advanced" categories. The classification is based on the degree of tumor contact with surrounding critical arteries and veins, providing essential imaging evidence for formulating surgical decisions and neoadjuvant therapy strategies.
Credit: Journal of Pancreatology
A landmark expert consensus from China offers a comprehensive roadmap for radiologists and surgeons to determine the resectability of pancreatic ductal adenocarcinoma (PDAC), a critical step in managing the aggressive cancer. The guidelines, formulated by the Group of Abdomen of the Chinese Society of Radiology, stress that the decision to operate should not rely on imaging alone but must involve a multidisciplinary team (MDT) at a high-volume center to integrate morphological, biological, and clinical factors.
The consensus solidifies dual-phase, thin-section contrast-enhanced CT as the first-line imaging method for evaluating the tumor's relationship with critical blood vessels, using standardized criteria to classify tumors as resectable, borderline resectable, or locally advanced. For detecting distant disease, the document makes a strong recommendation for contrast-enhanced MRI, especially with liver-specific agents and diffusion-weighted imaging (DWI), for identifying small liver metastases that often evade CT detection. "About 2% to 10% of PDAC diagnosed as resectable by CT examination were confirmed to have liver metastases by MRI," the authors note, underscoring its impact on surgical planning.
The consensus tackles complex clinical scenarios. For patients with borderline resectable tumors or high-risk factors, it recommends staging laparoscopy before initiating neoadjuvant therapy to identify occult peritoneal metastases. It also clarifies the roles of other modalities: FDG-PET/CT is not recommended for routine use or liver metastasis detection but may be considered for high-risk patients to find extra-pancreatic metastases. Chest CT is advised to rule out lung metastases, which carry a better prognosis than liver or peritoneal spread.
A significant challenge in pancreatic cancer care is assessing treatment response after neoadjuvant therapy. The consensus states that standard size-based criteria (RECIST) are not reliable, as inflammation and fibrosis can mimic viable tumor. Instead, a combination of imaging findings and trends in the tumor marker CA 19-9 is essential. For patients with no clear disease progression on imaging, laparoscopic exploration is preferred for definitive re-staging.
The authors highlight promising new technologies, including dual-source CT, perfusion CT, and radiomics, for evaluating treatment response and predicting vessel invasion but call for more multicenter research to validate their use. "With the progression of surgical technique and the application of neoadjuvant treatment, the evaluation of PDAC resectability is no longer limited to morphology," the panel concludes, advocating for a holistic, MDT-driven approach to improve the prognosis for pancreatic cancer patients in China.