{"entity":{"id":"resectable-pdac","kind":"cancer","name":"Resectable pancreatic ductal adenocarcinoma","aka":["Resectable pancreatic cancer","Operable pancreatic cancer","Early-stage PDAC","Stage I to II pancreatic adenocarcinoma"],"tldr":"Resectable pancreatic cancer is the minority of pancreatic cancer that the surgeon can remove with clear margins because it has not wrapped around the main arteries or spread. Treatment is an operation, usually a Whipple procedure, followed by six months of combination chemotherapy, which is what turns surgery alone into a real chance of cure.","summary":"Pancreatic ductal adenocarcinoma is called resectable when CT shows no contact with the superior mesenteric or coeliac arteries, no more than abutment of the portal or superior mesenteric vein, and no metastases. Most such tumours sit in the head of the gland and present with painless jaundice; body and tail tumours present later and are less often removable. Staging is a pancreas-protocol CT, a chest CT and CA 19-9, with endoscopic ultrasound and biopsy where the diagnosis is in doubt or neoadjuvant treatment is planned, and staging laparoscopy in some centres to find small peritoneal or liver deposits that CT misses.\n\nThe operation is a pancreatoduodenectomy (Whipple) for head tumours or a distal pancreatectomy with splenectomy for body and tail tumours, both with regional lymphadenectomy, increasingly by robotic or laparoscopic approach in high-volume centres. Surgery alone cures few patients: CONKO-001 (2007) showed that adjuvant gemcitabine roughly doubles the number alive without recurrence, ESPAC-4 (2017) that gemcitabine plus capecitabine does better, and PRODIGE 24 (2018) that six months of modified FOLFIRINOX after surgery gives the longest survival yet seen in the disease for patients fit enough to receive it. Roughly half of patients never complete adjuvant chemotherapy because of slow recovery, which is the main argument for giving some or all of it before surgery.\n\nWhether upfront chemotherapy helps clearly resectable tumours is not settled: PREOPANC-1 showed a benefit for neoadjuvant chemoradiation over upfront surgery in a mixed resectable and borderline population, but NORPACT-1 (2024) found no survival gain from neoadjuvant FOLFIRINOX in resectable disease, and the ALLIANCE A021806 trial is testing the question with modern chemotherapy. Every patient should be offered germline testing, because a BRCA, PALB2 or ATM variant changes chemotherapy choice and matters to relatives. Recurrence is common even after a complete resection and adjuvant chemotherapy, most often in the liver, and adjuvant trials of personalised mRNA vaccines (autogene cevumeran) and of the pan-RAS inhibitor daraxonrasib are trying to lower it.","asOf":"2026-09-18","wikipedia":"https://en.wikipedia.org/wiki/Pancreatic_cancer","links":[{"label":"Wikipedia","url":"https://en.wikipedia.org/wiki/Pancreatic_cancer"},{"label":"NCCN Guidelines: Pancreatic Adenocarcinoma","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1455"}],"tags":["subtype-page","gastrointestinal"],"related":["borderline-resectable-pdac","locally-advanced-pdac","metastatic-pdac","brca-palb2-pdac","ipmn-cystic-precursors","ampullary"],"cancers":[],"sections":[],"technologies":["robotic-surgery","cytotoxic-chemotherapy","ct","endoscopic-ultrasound-systems","biliary-stenting-drainage","germline-testing","neoantigen-mrna-vaccine","kras-inhibitors","eras-perioperative-nutrition","liquid-biopsy"],"targets":["kras","brca"],"drugs":["folfirinox","gemcitabine","capecitabine","gemcitabine-nab-paclitaxel","autogene-cevumeran","daraxonrasib","eli-002-7p"],"companies":["biontech","roche-genentech","revolution-medicines","elicio-therapeutics"],"institutions":[],"pathways":["pancreatic-cancer-signalling","ras-mapk"],"terms":["resectability","whipple","ca19-9","resection-margins","neoadjuvant-adjuvant","obstructive-jaundice","lymphadenectomy","ctdna","mrd","gbrca-mutation"],"trials":["prodige-24","preopanc","nct05968326","nct07252232","nct06538857","nct04969731","amplify-7p"],"people":["thierry-conroy","marc-besselink","vinod-balachandran","jurgen-weitz","richard-schulick","eileen-oreilly"],"bottlenecks":[],"keyPapers":["paper-rojas-mrna-neoantigen-vaccine-pancreatic-nature-2023","paper-burris-gemcitabine-pancreatic-jco-1997"],"journals":[],"dependsOn":[],"notes":[],"group":"gastrointestinal","burden":"About one in five pancreatic cancers is judged removable at diagnosis, usually because a tumour in the head of the pancreas blocked the bile duct and caused jaundice early. It is the only stage at which the disease is routinely cured.","subtypes":["Resectable PDAC of the pancreatic head (Whipple procedure)","Resectable PDAC of the body or tail (distal pancreatectomy)","Resectable PDAC with a raised CA 19-9 or large tumour (higher risk of occult spread, neoadjuvant chemotherapy considered)","Resectable PDAC with a germline BRCA or PALB2 variant (platinum-based chemotherapy)","Resectable PDAC arising in an IPMN (often earlier stage and better outcome)"],"biomarkers":["Pancreas-protocol CT for vessel contact and metastases (defines resectability)","CA 19-9 before and after surgery (prognosis, response, recurrence)","Resection margin status (R0 versus R1) and lymph node ratio","Germline testing for BRCA1, BRCA2, PALB2, ATM and Lynch genes in every patient","Tumour KRAS, TP53, CDKN2A and SMAD4 status (prognostic; SMAD4 loss favours distant spread)","Circulating tumour DNA after surgery (investigational marker of residual disease)"],"standardOfCare":[{"setting":"Staging","approach":"Pancreas-protocol CT, chest CT and CA 19-9; endoscopic ultrasound with biopsy when tissue is needed before treatment; biliary stenting only for cholangitis, deep jaundice or delayed surgery.","refs":["ct","ca19-9","endoscopic-ultrasound-systems","biliary-stenting-drainage","resectability"],"guideline":{"version":"NCCN Guidelines: Pancreatic Adenocarcinoma","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1455"}},{"setting":"Surgery","approach":"Pancreatoduodenectomy for head tumours, distal pancreatectomy with splenectomy for body and tail tumours, with regional lymphadenectomy; open, laparoscopic or robotic in high-volume centres.","refs":["whipple","robotic-surgery","lymphadenectomy","resection-margins"],"guideline":{"version":"NCCN Guidelines: Pancreatic Adenocarcinoma","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1455"}},{"setting":"Adjuvant chemotherapy","approach":"Six months of modified FOLFIRINOX for fit patients (PRODIGE 24); gemcitabine plus capecitabine (ESPAC-4) or gemcitabine alone (CONKO-001) for those who cannot tolerate it, started within twelve weeks of surgery.","refs":["folfirinox","prodige-24","gemcitabine","capecitabine","neoadjuvant-adjuvant"],"guideline":{"version":"NCCN Guidelines: Pancreatic Adenocarcinoma","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1455"}},{"setting":"Neoadjuvant chemotherapy","approach":"Considered for tumours with high-risk features (large size, very high CA 19-9, suspicious nodes) and increasingly offered in trials for all resectable disease; PREOPANC and NORPACT-1 are the evidence for and against.","refs":["folfirinox","preopanc","gemcitabine-nab-paclitaxel","neoadjuvant-adjuvant"],"guideline":{"version":"NCCN Guidelines: Pancreatic Adenocarcinoma","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1455"}},{"setting":"Germline testing","approach":"Offered to every patient at diagnosis; carriers of BRCA, PALB2 or ATM variants receive platinum-based chemotherapy and their relatives are offered testing and surveillance.","refs":["germline-testing","gbrca-mutation","pancreatic-surveillance"],"guideline":{"version":"NCCN Guidelines: Pancreatic Adenocarcinoma","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1455"}},{"setting":"Follow-up","approach":"CA 19-9 and CT every three to six months for two years then less often; recurrence is treated as metastatic or locally advanced disease.","refs":["ca19-9","ct"],"guideline":{"version":"NCCN Guidelines: Pancreatic Adenocarcinoma","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1455"}}],"stateOfArt":["Modified FOLFIRINOX after surgery (PRODIGE 24) is the adjuvant standard for fit patients and gives the longest survival recorded in a pancreatic cancer trial.","Neoadjuvant chemotherapy is spreading to resectable disease so that every patient receives systemic treatment, though NORPACT-1 did not show a survival gain.","Adjuvant trials of autogene cevumeran (personalised mRNA vaccine) and daraxonrasib are the first to attack recurrence with something other than chemotherapy.","Robotic pancreatoduodenectomy and enhanced recovery programmes shorten recovery and help more patients reach adjuvant chemotherapy."],"history":[{"year":1935,"title":"Allen Whipple describes the pancreatoduodenectomy that carries his name","refs":["whipple"]},{"year":2007,"title":"CONKO-001: adjuvant gemcitabine after resection lengthens disease-free survival","refs":["gemcitabine"]},{"year":2017,"title":"ESPAC-4: gemcitabine plus capecitabine beats gemcitabine alone after surgery","refs":["gemcitabine","capecitabine"]},{"year":2018,"title":"PRODIGE 24: six months of modified FOLFIRINOX after surgery sets the adjuvant standard","refs":["prodige-24","folfirinox","thierry-conroy"]},{"year":2020,"title":"PREOPANC-1: neoadjuvant chemoradiation before surgery improves long-term survival in resectable and borderline disease","refs":["preopanc","chemoradiation"]},{"year":2023,"title":"Autogene cevumeran phase 1: personalised mRNA vaccine after surgery raises T cells that track with staying recurrence-free","refs":["autogene-cevumeran","vinod-balachandran","paper-rojas-mrna-neoantigen-vaccine-pancreatic-nature-2023"]},{"year":2024,"title":"NORPACT-1: neoadjuvant FOLFIRINOX does not lengthen survival in clearly resectable disease","refs":["folfirinox"]}],"pipeline":["nct05968326","nct07252232","autogene-cevumeran","daraxonrasib","eli-002-7p","amplify-7p","nct06538857","nct04969731","idea-ras-inhibitor-neoadjuvant-pdac","idea-bio2-mrd-triggered-neoantigen-vaccine","idea-bio2-prehabilitation-standard"],"openProblems":["Half of patients never complete adjuvant chemotherapy; whether giving it first helps clearly resectable tumours is unproven.","Recurrence after a complete resection and full chemotherapy remains common, and no marker reliably identifies who is cured.","Circulating tumour DNA and CA 19-9 kinetics are not yet validated to guide who needs more or less treatment.","Outcomes differ sharply between high-volume and low-volume surgical centres."],"parent":"pancreatic"},"route":"/cancers/resectable-pdac/","neighbours":{"cancer":[{"id":"ampullary","kind":"cancer","name":"Ampullary cancer (ampulla of Vater)","route":"/cancers/ampullary/"},{"id":"borderline-resectable-pdac","kind":"cancer","name":"Borderline resectable pancreatic ductal adenocarcinoma","route":"/cancers/borderline-resectable-pdac/"},{"id":"brca-palb2-pdac","kind":"cancer","name":"BRCA or PALB2-mutant pancreatic ductal adenocarcinoma","route":"/cancers/brca-palb2-pdac/"},{"id":"ipmn-cystic-precursors","kind":"cancer","name":"Intraductal papillary mucinous neoplasm and other pancreatic cystic precursors","route":"/cancers/ipmn-cystic-precursors/"},{"id":"locally-advanced-pdac","kind":"cancer","name":"Locally advanced unresectable pancreatic ductal adenocarcinoma","route":"/cancers/locally-advanced-pdac/"},{"id":"metastatic-pdac","kind":"cancer","name":"Metastatic pancreatic ductal adenocarcinoma","route":"/cancers/metastatic-pdac/"},{"id":"pancreatic-acinar-cell-carcinoma","kind":"cancer","name":"Pancreatic acinar cell carcinoma","route":"/cancers/pancreatic-acinar-cell-carcinoma/"},{"id":"pancreatic","kind":"cancer","name":"Pancreatic ductal adenocarcinoma","route":"/cancers/pancreatic/"},{"id":"pancreatoblastoma","kind":"cancer","name":"Pancreatoblastoma","route":"/cancers/pancreatoblastoma/"}],"technology":[{"id":"biliary-stenting-drainage","kind":"technology","name":"Biliary stenting and drainage","route":"/technologies/biliary-stenting-drainage/"},{"id":"ct","kind":"technology","name":"CT (computed tomography)","route":"/technologies/ct/"},{"id":"cytotoxic-chemotherapy","kind":"technology","name":"Cytotoxic chemotherapy","route":"/technologies/cytotoxic-chemotherapy/"},{"id":"endoscopic-ultrasound-systems","kind":"technology","name":"Endoscopic ultrasound and EBUS systems","route":"/technologies/endoscopic-ultrasound-systems/"},{"id":"eras-perioperative-nutrition","kind":"technology","name":"Enhanced recovery (ERAS) and perioperative nutrition","route":"/technologies/eras-perioperative-nutrition/"},{"id":"germline-testing","kind":"technology","name":"Germline (hereditary) testing","route":"/technologies/germline-testing/"},{"id":"pancreatic-surveillance","kind":"technology","name":"High-risk pancreatic surveillance (CAPS / PRECEDE)","route":"/technologies/pancreatic-surveillance/"},{"id":"kras-inhibitors","kind":"technology","name":"KRAS & RAS inhibitors","route":"/technologies/kras-inhibitors/"},{"id":"liquid-biopsy","kind":"technology","name":"Liquid biopsy (ctDNA)","route":"/technologies/liquid-biopsy/"},{"id":"neoantigen-mrna-vaccine","kind":"technology","name":"Personalised neoantigen (mRNA) vaccines","route":"/technologies/neoantigen-mrna-vaccine/"},{"id":"robotic-surgery","kind":"technology","name":"Robotic & minimally invasive surgery","route":"/technologies/robotic-surgery/"}],"target":[{"id":"brca","kind":"target","name":"BRCA1 / BRCA2 (HRD)","route":"/targets/brca/"},{"id":"kras","kind":"target","name":"KRAS","route":"/targets/kras/"}],"drug":[{"id":"autogene-cevumeran","kind":"drug","name":"Autogene cevumeran","route":"/drugs/autogene-cevumeran/"},{"id":"capecitabine","kind":"drug","name":"Capecitabine","route":"/drugs/capecitabine/"},{"id":"daraxonrasib","kind":"drug","name":"Daraxonrasib","route":"/drugs/daraxonrasib/"},{"id":"eli-002-7p","kind":"drug","name":"ELI-002 7P","route":"/drugs/eli-002-7p/"},{"id":"folfirinox","kind":"drug","name":"FOLFIRINOX / mFOLFIRINOX","route":"/drugs/folfirinox/"},{"id":"gemcitabine","kind":"drug","name":"Gemcitabine","route":"/drugs/gemcitabine/"},{"id":"gemcitabine-nab-paclitaxel","kind":"drug","name":"Gemcitabine + nab-paclitaxel","route":"/drugs/gemcitabine-nab-paclitaxel/"}],"company":[{"id":"biontech","kind":"company","name":"BioNTech","route":"/companies/biontech/"},{"id":"elicio-therapeutics","kind":"company","name":"Elicio Therapeutics","route":"/companies/elicio-therapeutics/"},{"id":"revolution-medicines","kind":"company","name":"Revolution Medicines","route":"/companies/revolution-medicines/"},{"id":"roche-genentech","kind":"company","name":"Roche / Genentech","route":"/companies/roche-genentech/"}],"pathway":[{"id":"pancreatic-cancer-signalling","kind":"pathway","name":"Pancreatic cancer (KEGG map)","route":"/pathways/pancreatic-cancer-signalling/"},{"id":"ras-mapk","kind":"pathway","name":"RAS / RAF / MEK / ERK (MAPK)","route":"/pathways/ras-mapk/"}],"term":[{"id":"ca19-9","kind":"term","name":"CA 19-9","route":"/terms/ca19-9/"},{"id":"chemoradiation","kind":"term","name":"Chemoradiation (chemoradiotherapy, CRT)","route":"/terms/chemoradiation/"},{"id":"ctdna","kind":"term","name":"Circulating tumour DNA (ctDNA)","route":"/terms/ctdna/"},{"id":"gbrca-mutation","kind":"term","name":"Germline BRCA mutation (gBRCA)","route":"/terms/gbrca-mutation/"},{"id":"lymphadenectomy","kind":"term","name":"Lymphadenectomy (lymph node dissection)","route":"/terms/lymphadenectomy/"},{"id":"mrd","kind":"term","name":"Minimal / molecular residual disease (MRD)","route":"/terms/mrd/"},{"id":"neoadjuvant-adjuvant","kind":"term","name":"Neoadjuvant / adjuvant / perioperative","route":"/terms/neoadjuvant-adjuvant/"},{"id":"obstructive-jaundice","kind":"term","name":"Obstructive jaundice and biliary obstruction","route":"/terms/obstructive-jaundice/"},{"id":"resectability","kind":"term","name":"Resectable, borderline resectable and unresectable","route":"/terms/resectability/"},{"id":"resection-margins","kind":"term","name":"Resection margins (R0 / R1 / R2)","route":"/terms/resection-margins/"},{"id":"whipple","kind":"term","name":"Whipple procedure (pancreaticoduodenectomy)","route":"/terms/whipple/"}],"trial":[{"id":"nct05968326","kind":"trial","name":"A Study of the Efficacy and Safety of Adjuvant Autogene Cevumeran Plus Atezolizumab and mFOLFIRINOX Versus mFOLFIRINOX Alone in Participants With Resected PDAC","route":"/trials/nct05968326/"},{"id":"amplify-7p","kind":"trial","name":"AMPLIFY-7P","route":"/trials/amplify-7p/"},{"id":"nct06538857","kind":"trial","name":"CEB-01 in Locally Resectable Pancreatic Cancer","route":"/trials/nct06538857/"},{"id":"preopanc","kind":"trial","name":"PREOPANC-1 / PREOPANC-2","route":"/trials/preopanc/"},{"id":"prodige-24","kind":"trial","name":"PRODIGE 24 / CCTG PA6","route":"/trials/prodige-24/"},{"id":"nct04969731","kind":"trial","name":"Safety and Efficacy of Immuncell-LC With Gemcitabine in Resectable Pancreatic Cancer","route":"/trials/nct04969731/"},{"id":"nct07252232","kind":"trial","name":"Study of Daraxonrasib (RMC-6236) in Patients With Resected Pancreatic Ductal Adenocarcinoma (PDAC)","route":"/trials/nct07252232/"}],"person":[{"id":"eileen-oreilly","kind":"person","name":"Eileen M. O'Reilly","route":"/people/eileen-oreilly/"},{"id":"jurgen-weitz","kind":"person","name":"Jürgen Weitz","route":"/people/jurgen-weitz/"},{"id":"marc-besselink","kind":"person","name":"Marc G. Besselink","route":"/people/marc-besselink/"},{"id":"richard-schulick","kind":"person","name":"Richard Schulick","route":"/people/richard-schulick/"},{"id":"thierry-conroy","kind":"person","name":"Thierry Conroy","route":"/people/thierry-conroy/"},{"id":"vinod-balachandran","kind":"person","name":"Vinod P. Balachandran","route":"/people/vinod-balachandran/"}],"paper":[{"id":"paper-burris-gemcitabine-pancreatic-jco-1997","kind":"paper","name":"Burris 1997: gemcitabine becomes the first standard treatment for advanced pancreatic cancer","route":"/key-papers/paper-burris-gemcitabine-pancreatic-jco-1997/"},{"id":"paper-rojas-mrna-neoantigen-vaccine-pancreatic-nature-2023","kind":"paper","name":"Rojas 2023: a personalised mRNA vaccine trained T cells against each patient's pancreatic cancer, and those who responded stayed cancer-free longer","route":"/key-papers/paper-rojas-mrna-neoantigen-vaccine-pancreatic-nature-2023/"}],"idea":[{"id":"idea-bio2-prehabilitation-standard","kind":"idea","name":"Four weeks of training and nutrition before major cancer surgery, as standard","route":"/ideas/idea-bio2-prehabilitation-standard/"},{"id":"idea-bio2-mrd-triggered-neoantigen-vaccine","kind":"idea","name":"Personalised vaccines given only when the blood test turns positive","route":"/ideas/idea-bio2-mrd-triggered-neoantigen-vaccine/"},{"id":"idea-ras-inhibitor-neoadjuvant-pdac","kind":"idea","name":"RAS(ON) inhibitors to convert unresectable pancreatic cancer to resectable","route":"/ideas/idea-ras-inhibitor-neoadjuvant-pdac/"}]}}