How do you approach the management of borderline resectable pancreatic cancer in patients with superior mesenteric artery vs vein abutment ?

This is an area where treatment paradigms are in flux. If there is no vascular abutment our usual policy is resection followed by adjuvant treatment. With the augmented response rates being seen with FOLFOXIRI and gemcitabine + nab paclitaxel there is a better chance that tumor shrinkage off of vasculature can be achieved either with chemotherapy alone or several cycles of chemotherapy plus radiation with 5-FU sensitization. In general, if there is any abutment of the SMA or SMV, we will start with chemotherapy and determine if and when to add radiation on a case by case basis. In cases with good responses surgery will follow chemotherapy avoiding the potential long term toxicities of radiation. It is often impossible to make a judgement ab...