Sixty-two-year-old female presented with a 2-week history of abdominal pain. Work-up included a right upper quadrant ultrasound, CT scan of the abdomen/pelvis, and MRCP that revealed a pancreatic head mass and a dilated pancreatic duct. She subsequently underwent ERCP with pancreatic stent placement. Two weeks later, an endoscopic ultrasound was performed where a 24 × 28 mm pancreatic head mass was confirmed. FNA was performed at this time and confirmed pancreatic adenocarcinoma. She underwent repeat CT scan of the abdomen/pelvis and chest where no metastatic disease was noted.

She completed her treatment 6 months after diagnosis. Restaging CT scan revealed a decrease in size in her primary tumor with less abutment on the portal vein and no evidence of metastatic disease.

To assess for a possible pancreatic tumor, the National Comprehensive Cancer Network (NCCN) recommends obtaining a multidetector computerized tomography (CT) scan using a pancreatic protocol [1]. This “triple-phase” CT ensures thin cut (5–10 mm) images obtained in the non-contrast, arterial phase and pancreatic parenchyma/portal venous contrast phases in addition to a low-density oral contrast. This protocol assists in visualizing the tumor and the surrounding vasculature, as assessing its relationship to the vessels (which include the portal vein, splenic vein, superior mesenteric vein and artery, celiac axis, and gastroduodenal artery (GDA)) helps determine resectability. A pancreas protocol CT scan has good sensitivity (89–97%) and negative predictive value [2] in detecting a pancreatic mass. In addition to assessing the pancreas and its surrounding structures, this imaging study has the capability of ruling out metastatic disease. A magnetic resonance imaging (MRI) study could be performed if the patient was unable to obtain a CT scan.

Once there is suspicion of a pancreatic tumor on CT scan, endoscopic ultrasound (EUS) is generally performed to further characterize the lesion as well as to obtain a tissue diagnosis [3]. If the patient is to obtain neoadjuvant treatment, this tissue biopsy is imperative. In addition, a therapeutic endoscopic cholangiopancreatography (ERCP) procedure can be performed in the same setting if the patient is demonstrating signs of biliary or pancreatic duct obstruction [3].

When assessing the primary tumor, it is imperative to assess its relationship to surrounding vascular structures and its resectability, as resectability helps determine treatment strategies. Historically, the term “borderline” was used to describe those patients who had a high risk of a positive surgical margin secondary to the anatomic relationship of the tumor to vessels. Many different definitions have been described and used in the literature, therefore making comparing studies and outcomes difficult. The National Comprehensive Cancer Network (NCCN) and the International Study Group of Pancreatic Surgery (ISGPS) define borderline resectable pancreatic cancer (BRPC) as CT findings of venous distortion of the SMV/portal venous axis even including short-segment venous occlusion with proximal and distal sufficient vessel length allowing safe reconstruction; encasement of the gastroduodenal artery up to the hepatic artery, with either short-segment encasement or direct abutment of the hepatic artery without extension to the celiac axis; and tumor abutment of the SMA but with no greater than 180° of the vessel wall circumference.

Further metastatic staging should be performed in these patients regardless of whether there is metastatic disease present in the abdomen. A CT of the chest will suffice. Obtaining a positron-emission tomography (PET) scan is controversial, and currently there are no strong recommendations to obtain this [3]. In patients who are high risk for occult metastatic disease, a staging laparoscopy is recommended. Most institutions only perform staging laparoscopy on patients with a resectable tumor [4], as the presence of metastatic disease would change management on these patients. However, if the patient is going directly to surgery or if their chemotherapy treatment strategy would differ if they had metastatic disease, a staging laparoscopy in borderline or locally advanced patients is indicated.