The Mesopancreas remains at risk in primary resectable pancreatic cancer patients: time to reappraise resectability criteria?

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is associated with poor survival, and complete surgical resection with a negative circumferential resection margin (R0CRM-) remains the only potentially curative treatment. Current resectability criteria primarily stratify patients according to arterial and portomesenteric venous involvement. However, the impact of mesopancreatic infiltration on resection margin status within these classifications remains unclear.

METHODS

A consecutive cohort of 271 patients undergoing upfront resection for primarily resectable or borderline resectable PDAC of the pancreatic head was analyzed. Preoperative staging was reassessed according to current NCCN resectability criteria using multidetector CT. Histopathological evaluation followed the LEEPP protocol and 1-mm CRM definition. Mesopancreatic infiltration was correlated with resectability status and margin involvement.

RESULTS

Among 271 patients, 209 (77.1%) were classified as primarily resectable and 62 (22.9%) as borderline resectable. Mesopancreatic infiltration was present in 208 patients (76.9%). Overall, R0CRM- resection was achieved in 143 patients (52.8%), while 128 patients (47.2%) had R1/R0CRM+ margins. In primarily resectable patients, mesopancreatic infiltration was significantly associated with incomplete total resection (p=0.004) and dorsal margin positivity (p=0.026). Across the entire cohort, mesopancreatic involvement increased the likelihood of incomplete resection by 2.71-fold (95% CI 1.35-5.43; p=0.005). In contrast, NCCN-based resectability classification did not significantly correlate with total or dorsal margin status.

CONCLUSION

Mesopancreatic infiltration is frequent and associated with an increased risk of incomplete oncologic clearance, including in patients classified as primarily resectable. These findings suggest that mesopancreas-related features may merit consideration in future refinements of resectability assessment.