Ductal Adenocarcinoma: Downstaging

Pancreatic ductal adenocarcinoma (PDAC) is usually diagnosed at an advanced stage of disease with involvement of major peripancreatic vessels, extra-pancreatic invasion, or metastases. For this reason, fewer than 20% of patients are suitable for surgical resection (Laeseke et al., Radiology 277:644–661, 2015). An increasing number of unresectable PDACs undergo surgery after neoadjuvant therapy. Unresectable PDAC patients, including locally advanced and borderline resectable cancers, can be downstaged by neoadjuvant chemoradiotherapy. Resectability of PDAC is a multidisciplinary concept, and imaging has a central role for the proper description of the extent of tumor. High-quality imaging of the pancreas should be performed at presentation and following neoadjuvant treatments to provide adequate staging and assessment of resectability status. Restaging after chemotherapy is always more problematic with a lower accuracy by using imaging modalities to correctly assess therapeutic responses and downstaging.