Please cite this article in press as: Petrelli F, et al. Borderline resectable pancreatic cancer: More than an anatomical concept. Dig Liver Dis (2016), http://dx.doi.org/10.1016/j.dld.2016.11.010 ARTICLE IN PRESS G Model YDLD-3298; No. of Pages 4 Digestive and Liver Disease xxx (2016) xxx–xxx Contents lists available at ScienceDirect Digestive and Liver Disease jou rnal h om epage: www.elsevier.com/locate/dld Progress Report Borderline resectable pancreatic cancer: More than an anatomical concept Fausto Petrelli a,* , Alessandro Inno b , Sandro Barni a , Antonio Ghidini c , Roberto Labianca d , Massimo Falconi e , Michele Reni f , Stefano Cascinu g , on behalf of GISCAD (Gruppo Italiano per lo Studio dei Carcinomi dell’Apparato Digerente) and San Raffaele Hospital a Medical Oncology Unit, ASST Bergamo Ovest, Bergamo, Italy b Medical Oncology Unit, Sacro Cuore Don Calabria Hospital, Verona, Italy c Medical Oncology Unit, Casa di Cura Igea, Milano, Italy d Medical Oncology Unit, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy e Surgical Department of Pancreas, San Raffaele Hospital, IRCCS, Milano, Italy f Medical Oncology Unit, San Raffaele Hospital, IRCCS, Milano, Italy g Department of Oncology and Hematology, University of Modena and Reggio Emilia, Modena, Italy a r t i c l e i n f o Article history: Received 28 July 2016 Accepted 15 November 2016 Available online xxx Keywords: Borderline resectable Pancreatic cancer Treatment a b s t r a c t Borderline resectable pancreatic cancer (BRPC) accounts for about 10–15% of newly diagnosed pancreatic cancer, and its management requires a skilled multidisciplinary team. The main definition of BRPC refers to resectability, but also a high risk of positive surgical margins and recurrence. This raises questions about the value of surgery and suggests an opportunity to utilize preoperative treatment in this subset of patients. Besides technical borderline resectable disease which is defined on anatomical and radiological criteria, there is also a biological borderline resectable disease which is defined on clinical and biological prog- nostic factors. Technical borderline resectable disease requires tumor shrinkage with aggressive therapy including modern drug combinations +/- radiotherapy to achieve radical surgery. Biological BRPC needs always an early systemic treatment in order to select the best candidates for subsequent radical surgery. It is important to distinguish between these different clinical scenarios, both in clinical practice and for clinical trials design. © 2016 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l. 1. Introduction The definition of borderline resectable pancreatic cancer (BRPC) is a much debated issue. Several different versions have been pro- posed over the years, all of them based on the extent of vessel involvement (venous and arterial) by the tumor. The main defi- nition of BRPC refers to a concept of technical resectability, but also a high risk of positive surgical margins and recurrence [1–5]. This raises questions about the real value of surgery and suggests an opportunity to utilize preoperative treatment in this subset of patients. However, given that around 60% of patients undergoing radical surgery die within 18–24 months of the procedure, it is easy to acknowledge that upfront surgery is the best treatment approach for only a minority of patients. * Corresponding author at: Medical Oncology Unit, ASST Bergamo Ovest, Piazzale Ospedale 1, 24047 Treviglio, Bergamo, Italy. Fax: +39 0363424380. E-mail address: faupe@libero.it (F. Petrelli). This leads to the substantial need to expand the concept of what is a borderline resectable tumor. In reality, along with the one feature that is classically identified by anatomical definition criteria, some other clinical, pathological, and biological features may help us to identify resectable patients who would not benefit from surgery. In other words, borderline resectable tumors could be divided into two different entities: • Technical borderline: tumors involving vessels to a limited extent and for which resection would likely be compromised by positive surgical margins (Table 1). • Biological borderline: tumors that, despite technical resectabil- ity, have an unfavorable biology that leads to an early relapse or death. Both technical and biological borderline resectable tumors should require systemic treatment before surgery, albeit with dif- ferent aims. http://dx.doi.org/10.1016/j.dld.2016.11.010 1590-8658/© 2016 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l.