Anatomical Classification and Staging Systems of Borderline Resectable and Locally Advanced Pancreatic Cancer—A Subgroup Analysis of the NORPACT-2 Trial

Abstract

Background: This study aims to provide a detailed understanding of resectability and prognosis within anatomical subgroups of borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC) on the basis of established classification systems. Patients and Methods: Patients with BRPC/LAPC, defined by National Comprehensive Cancer Network (NCCN) criteria, were prospectively included from 2018 to 2020. BRPC was subcategorized by vascular involvement and LAPC by the Louisville (Lv) classification system, and both cohorts were reclassified according to the Dutch (DPCG) criteria. NCCN-defined primary resectable pancreatic cancer (PC) cases that met DPCG-BRPC criteria were included in the analysis. Results: In total, 228 patients (96 NCCN-BRPC, 92 NCCN-LAPC, and 40 reclassified from NNCN primary resectable PC to DPCG-BRPC) were included. NCCN-BRPC exhibiting both venous and arterial involvement had a lower resection rate (odds ratio (OR) 0.22, p = 0.038). Isolated vein involvement and baseline cancer antigen (CA)19–9 levels < 500 kU/L predicted resectability (OR 5.99, p = 0.005) and survival (hazard ratio (HR) 0.47, p = 0.024). DPCG-BRPC demonstrated higher resectability rates (67.4% versus 46.9%, p = 0.004) and fewer vascular resections (37% versus 58%, p = 0.031) compared with NCCN-BRPC. While the NCCN only predicted resectability, DPCG also predicted survival. No patients with Lv type IIIc2–4 (nonreconstructable invasion of the portomesenteric vein combined with arterial involvement) underwent resection, and this subgroup had worse survival (HR 2.08, p = 0.021). Conclusions: Variations within established classification systems for BRPC/LAPC impact prediction of survival and resectability. A more detailed understanding of the anatomical subgroups in BRPC and LAPC, alongside CA19–9 levels, could enhance patient stratification regarding tumor resectability and neoadjuvant strategies.