A 55-year-old man presents with painless progressive jaundice, weight loss, and a positive Courvoisier's sign. ERCP shows a short stricture at the lower end of the common bile duct. CA 19-9 is 840 U/mL. CT shows a 3.2 cm head-of-pancreas mass with portal vein abutment (< 180° contact, no distortion). According to borderline resectability criteria (AHPBA/NCCN), what is the standard management?
- A Immediate Whipple's pancreaticoduodenectomy
- B Palliative biliary bypass (hepaticojejunostomy) and gastrojejunostomy
- C Neoadjuvant therapy (FOLFIRINOX or gemcitabine + nab-paclitaxel) followed by restaging and surgery ✓
- D ERCP stenting only, with systemic chemotherapy indefinitely
Explanation
Borderline resectable pancreatic cancer (BRPC) is defined by specific vascular involvement criteria: SMA or coeliac abutment ≤180°, short segment portal/SMV abutment or impingement (≤180°, reconstructable), and no hepatic artery involvement. For BRPC, neoadjuvant chemotherapy (FOLFIRINOX preferred if PS 0-1; gem-nab paclitaxel for PS 2) is the standard approach, aiming to downstage the tumour, test biology (poor outcome if rapidly progressing), and improve R0 resection rate. ALLIANCE trial data support neoadjuvant over upfront surgery in BRPC. Palliative bypass would be premature for potentially resectable disease.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.