Determining Resectability of Periampullary Tumors
Anatomical Resectability Criteria (NCCN Classification)
- Periampullary tumors should be classified as resectable, borderline resectable, locally advanced, or metastatic using NCCN anatomical criteria based on vessel involvement, supplemented by biological factors and conditional factors, with final determination made through multidisciplinary team discussion at an expert center, as recommended by the National Comprehensive Cancer Network (NCCN) 1, 2
- The degree of contact between tumor and peripancreatic vessels determines resectability status, according to the NCCN classification 1
- No arterial involvement is defined as no contact with superior mesenteric artery (SMA), celiac trunk, or common hepatic artery, as per the NCCN guidelines 1
- Limited venous involvement is defined as no contact or ≤180° contact with superior mesenteric vein (SMV) or portal vein (PV) without vein contour irregularity, as stated by the NCCN 1
Biological and Conditional Factors
- CA 19-9 >500 IU/ml indicates more aggressive disease, according to the International Association of Pancreatology consensus 1
- Regional lymph node metastases are diagnosed by biopsy or PET-CT, as recommended by the International Association of Pancreatology 1
- ECOG performance status 2 impacts treatment eligibility and surgical candidacy, as stated by the NCCN 1
Mandatory Multidisciplinary Team Review
- MDTB discussion in expert centers is required to define treatment strategy accounting for nutritional status, performance status, and comorbidities, as recommended by the NCCN 1
- Specialized centers achieve better outcomes, with operative mortality should be <10% in experienced hands, according to the NCCN 2
Special Considerations
- Stage 4 duodenal polyposis warrants surgical resection via pylorus-preserving pancreaticoduodenectomy, as recommended by the European Society of Gastrointestinal Endoscopy 3, 2
- Surveillance intervals for familial adenomatous polyposis (FAP) are every 5 years for stage 0/1, every 3 years for stage 2, and every 1-2 years for stage 3, as stated by the European Society of Gastrointestinal Endoscopy 3