Multidisciplinary Therapeutic Approaches to Pancreatic Cancer According to the Resectability Status

Abstract

Pancreatic ductal adenocarcinoma (PDAC) is among the most lethal cancers, characterized by late diagnosis, rapid progression, and limited therapeutic options. Despite advancements, only 20% of patients are eligible for surgical resection at diagnosis, the sole curative treatment. Multidisciplinary evaluation is critical to optimize care, stratifying patients based on resectability into resectable, borderline resectable, locally advanced, and metastatic stages. Preoperative imaging, such as computed tomography (CT) and endoscopic ultrasound (EUS), remains central for staging, for vascular assessment, and tissue acquisition. Endoscopic and systemic approaches are pivotal for addressing complications like biliary obstruction and improving outcomes. Endoscopic retrograde cholangiopancreatography (ERCP) has been considered for years the gold standard for biliary drainage, although EUS-guided drainage is increasingly utilized due to its efficacy in both resectable and unresectable disease. Systemic therapies play a key role in neoadjuvant, adjuvant, and palliative settings, with ongoing trials exploring their impact on survival and resectability chance. This review highlights the evolving multidisciplinary approaches tailored to the disease stage, focusing on biliary drainage techniques, systemic therapies, and their integration into comprehensive care pathways for PDAC. The continuous refinement of these strategies offers incremental survival benefits and underscores the importance of personalized, multidisciplinary management.

Keywords: ERCP; EUS-guided intervention; biliary drainage; chemotherapy; neoadjuvant therapy; pancreatic ductal adenocarcinoma; staging.

Figure 1

Visual representation of Abutment, Encasement, and Invasion of a vessel.

Figure 2

Imaging findings of pancreatic body adenocarcinoma. (a) Axial contrast-enhanced CT scan in the portal venous phase demonstrating hypovascular pathological tissue (arrowhead) encasing the proximal splenic artery. (b) Arterial-phase CT scan with oblique plane MIP reconstruction highlighting the irregular narrowing of the celiac trunk and splenic artery (white arrow), which is encased by hypovascular tumor tissue arising from the pancreatic body. (c) Arterial-phase CT scan with sagittal MIP reconstruction showing hypovascular tumor tissue completely surrounding the splenic artery, originating from the pancreatic body. (d) Three-dimensional volume rendering illustrating the spatial relationship between the tumor (highlighted in green) and the splenic artery, which is entirely encased by the neoplastic mass.

Figure 3

EUS evaluation of pancreatic cancer of the head. (a) B-mode evaluation showing hypovascular lesion with irregular margins; (b) e-Flow with identification of superior mesenteric artery (star) and venous (arrow); (c) EUS elastography showing rigid solid mass suggestive for pancreatic cancer.

Figure 4

Practical algorithm for the management of pancreatic cancer. CE, contrast-enhanced; EUS-TA, endoscopic ultrasound, tissue acquisition; BD, biliary drainage; NAT, neoadjuvant therapy; CRT, Chemo-radio therapy; SBRT, stereotactic body radiotherapy.