title: Borderline resectable pancreatic tumors: is there a need for further refinement of this stage?
abstract: BACKGROUND
  The ideal treatment of patients with "borderline resectable pancreatic tumors (BRTs)" needs to be established. Current protocols advise neoadjuvant chemo(radio)therapy, although some patients may appear to have BRT on preoperative imaging and a complete resection may be achieved without the need for vascular resection. The aim of the present study was to identify specific findings on preoperative imaging that could help predict in which patients with BRT a complete resection, with or without vascular resection (VR), could be achieved.
  
  
  METHODS
  Twelve patients with BRTs were identified. Tumor location, maximum degree of circumferential contact (CC), length of contact of the tumor with major vessels (LC), and luminal narrowing of vessels at the point of contact with the tumor (venous deformity, VD) were graded on preoperatively acquired multidetector computed tomography (MDCT) images and then compared with the intraoperative findings and need for VR.
  
  
  RESULTS
  A complete resection (R0) was achieved in 10 patients with 2 having microscopic positive margins (R1) on histopathology at the uncinate margin. Four of the 10 patients required VR (40%). In 3 of the 4 patients whose tumors required VRs, CC was ≥grade III and VD was grade 2. LC did not influence the need for VR.
  
  
  CONCLUSIONS
  It is possible to achieve a complete resection at the first instance in patients found to have BRTs on preoperative imaging. Preoperative MDCT-based grading systems and our proposed criteria may help identify such patients, thus avoiding any delay in curative resections in such patients.
authors.affiliation: Department of Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Mumbai, India. shailushrikhande@hotmail.com
authors.forename: Shailesh V
authors.initials: SV
authors.lastname: Shrikhande
authors.forename: Supreeta
authors.initials: S
authors.lastname: Arya
authors.forename: Savio George
authors.initials: SG
authors.lastname: Barreto
authors.forename: Sachin
authors.initials: S
authors.lastname: Ingle
authors.forename: Melroy A
authors.initials: MA
authors.lastname: D'Souza
authors.forename: Rohini
authors.initials: R
authors.lastname: Hawaldar
authors.forename: Parul J
authors.initials: PJ
authors.lastname: Shukla
mesh_terms: D000230:Adenocarcinoma / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D001808:Blood Vessels / Q000473:pathology; D017024:Chemotherapy, Adjuvant; D005260:Female; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D018579:Patient Selection; D011237:Predictive Value of Tests; D018714:Radiotherapy, Adjuvant; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures; D055815:Young Adult