In parallel to the evolution in treatment of pancreatic cancer, there has been equally impressive progress in the imaging of this disease and in the ability to radiographically characterize the stage and biology of individual tumors. Understanding the technical developments in these areas underlines the importance of effective multidisciplinary collaboration. Thin slice multi-detector CT imaging with oral and intravenous contrast, using non-contrast, arterial, pancreatic parenchymal, and portal venous phases, is critical to accurate assessment of the tumor and blood vessels. Anything less than the full pancreatic protocol sequences results in suboptimal imaging [38, 39]. If the patient has a contrast allergy, renal insufficiency, is pregnant or has inconclusive results on CT, then a pancreas protocol MRI may be used. MRI can be of particular value if small metastases to the liver or peritoneum are suspected [40]. Diffusion weighted MRI may even be of value in predicting response to neoadjuvant therapy [41]. Positron emission tomography (PET) scanning is increasingly being used to assist in planning for radiation therapy and to detect early metastatic disease not seen on routine imaging [42, 43]. It may also distinguish benign peripancreatic inflammation from metastases or local extension of malignancy [44].

Accurate staging is particularly germane in the management of patients with borderline resectable and locally advanced pancreatic cancer where agreement on definition is critical and standards of care are just now being developed to enable standardization of the therapeutic approach. The Society of Abdominal Radiology and the American Pancreatic Association have constructed a radiology reporting template which ensures that there is high quality and reproducibility to the reports, and this approach should rapidly be adopted by all institutions [45]. An abbreviated version of this template, as pertains to the critical vascular structures, is illustrated in Table 5.2.

Following surgery, the College of American Pathologists recommends a comprehensive and standardized analysis of each resected tumor which includes size, margins, histologic grade, nodal involvement, vascular involvement, lymphovascular invasion, perineural invasion, intraepithelial neoplasia, and any evidence of chronic pancreatitis [8]. This has permitted a more accurate assessment of the cancer prior to and following any therapeutic intervention and a more effective selection of appropriate local and systemic therapy. Handling of specimens, margin analysis, and the definition of an R1 resection still differs among pathologists in the USA and Europe. These variations need to be considered when analyzing study results [46]. An assessment of response to neoadjuvant therapy by the group at MDACC has determined that a full pathologic complete remission (2.7 %) or presence of minimal residual disease (16.1 %) following therapy has a much better prognosis than a moderate (55.6 %) or minimal response (25.6 %) and correlates with better survival [47].

In the last 5 years, we have seen remarkable advances in endoscopic and interventional radiologic capabilities. Upper endoscopy , ERCP, and EUS have made a significant impact on the safety and accuracy of diagnosis and staging and on the management of common problems such as pain (celiac axis block) [48], biliary obstruction [49], duodenal obstruction, and postoperative complications. Duodenal obstruction has become an increasingly common problem in locally advanced disease as modern therapy has extended survival, with one recent series reporting an incidence of 38 % [50]. Treating duodenal obstruction has become relatively routine, but managing the concomitant biliary obstruction when that occurs, frequently requires multidisciplinary experience. Creative endoluminal techniques such as double stenting and transmural biliary drainage techniques may be needed [51, 52].

Advances in interventional radiology have greatly contributed to improved management of symptoms related to disease and thus have allowed patients to initiate and complete neoadjuvant therapy. Percutaneous approaches to celiac neurolysis have improved the management of epigastric and back pain associated with celiac plexus infiltration [53], and percutaneous endovascular stenting has alleviated symptoms of intestinal and hepatic ischemia from tumor invasion into the SMA or hepatic arteries [8]. Percutaneous transhepatic portovenous stenting has been shown to be effective in the management of ascites resulting from portovenous tumor thrombus [54]. Finally, splenic artery embolization for non-operative management of low platelet counts as a result of hypersplenism has allowed continuation of dose-intensive chemotherapy in cases in which this has been important [55].

All these developments have created a menu of therapeutic and palliative treatment options that, individually, have uncertain potential benefit for any given patient. Each of the options in this menu has to be duly considered, with the risks and benefits carefully weighed. The optimal way to do so is to have every patient evaluated by individual experts from each of the disciplines involved, for there to be discussion among the members of that team, and a consensus approach to care developed.

Abundant evidence exists to support the notion that multimodality management of pancreatic cancer is associated with improved outcomes, with some centers demonstrating 5-year survival rates as high as 27 % among patients treated with multimodality therapy compared to 10–15 % in historical series with surgery alone [56]. There is also, however, considerable evidence that compliance with established national guidelines, such as that of the NCCN [8], remains disappointingly low [57], that there is considerable variability in the quality of the treatment of pancreatic cancer in the USA and that multimodality care is, as yet, still quite uncommon [58]. The optimal way to foster this multimodality care bears some scrutiny as different approaches may work better in different settings, and various disease specific groups may learn from one another. As the complexity of oncologic care continues to increase, it will be more important than ever that all involved in the care of the patient be experienced, knowledgeable, and current on new developments and that these experts communicate effectively.

With the above infrastructure in place, a given case can be duly considered and the critical decisions necessary for optimal therapy can be made. As this decision-making takes place, a number of issues are critical. First, the goals of therapy must be clearly delineated—cure versus palliation versus other. It may not always be possible to do this, especially in borderline resectable disease where ultimate curability is uncertain, but a thorough understanding of the status quo on the part of the patient is essential if his/her expectations regarding the ultimate outcome are to be realistic. Second, the determination of eligibility for clinical studies is vital if important progress is to be made in this disease. It is estimated that only a very small fraction of all eligible patients are enrolled in clinical studies (3 %), with underserved populations rarely, if ever, exposed to available clinical studies and particularly prone to being neglected in this regard [88]. Third, individualized plans are ideally made with consideration given to stage of disease, tumor molecular profile, inheritance patterns, comorbidities, performance status, fragility scores, and cultural issues. Fourth, the skill set of the treating physicians and institutional experience must be considered. Many recent studies have demonstrated that outcomes of complex surgical procedures are better when the procedures are done in large centers performing a critical number of procedures on an annual basis [57]. When centers and physicians attempt procedures and therapies that they are not equipped or experienced enough to effectively carry forward, patients will not infrequently then need to be referred to tertiary centers where they may be offered second operations or attempts at treatment. Second procedures frequently do not have the desired results and an opportunity to cure may be lost [56]. Despite existing data supporting the importance of experience, there does not appear to be a migration to high-volume centers. There is a perception on the part of patients that remaining close to home is of definite benefit, and many procedures continue to happen in less experienced settings [57].