Borderline resectable pancreatic ductal adenocarcinoma
Borderline resectable pancreatic cancer touches the big blood vessels behind the pancreas, so an operation straight away would probably leave cancer behind. Chemotherapy first, usually FOLFIRINOX for several months and sometimes radiotherapy, shrinks the edge of the tumour, and patients whose disease has not spread go on to surgery with a better chance of a clean removal.
Overview
Borderline resectable disease is defined anatomically: tumour contact with the superior mesenteric or portal vein that is reconstructable, abutment of the superior mesenteric artery of 180 degrees or less, or limited contact with the hepatic artery. The MD Anderson, NCCN and international consensus definitions differ in detail and some add biological criteria, such as a very high CA 19-9 or suspicious regional nodes, and conditional criteria such as poor performance status. The point of the category is that upfront surgery leaves a positive margin in a large share of patients and that neoadjuvant treatment selects those who will benefit from a difficult operation.
Neoadjuvant therapy is standard. PREOPANC-1 (2020, long-term follow-up 2022) randomised resectable and borderline patients to gemcitabine-based chemoradiation before surgery or upfront surgery and found more clear-margin resections and better long-term survival, with the benefit concentrated in the borderline group. PREOPANC-2 then compared neoadjuvant FOLFIRINOX with gemcitabine chemoradiation and found no difference, and ESPAC-5 found that neoadjuvant chemotherapy beat immediate surgery for borderline disease. Modified FOLFIRINOX for two to four months is the usual regimen, with gemcitabine plus nab-paclitaxel for less fit patients. The role of radiotherapy after chemotherapy is disputed: ALLIANCE A021501 (2022) stopped its stereotactic radiotherapy arm early because outcomes were worse than with chemotherapy alone, while other groups use conventional or ablative chemoradiation to secure the arterial margin.
After neoadjuvant treatment patients are restaged with CT and CA 19-9; radiological shrinkage is often modest even when the tumour has responded, so surgeons operate on patients with stable disease, falling CA 19-9 and good fitness. Resection with venous reconstruction is routine in specialist centres and arterial resection is done selectively. Pathological response predicts survival, and patients complete a total of six months of chemotherapy after surgery where possible. Germline testing is offered to all, and a BRCA or PALB2 variant argues for a platinum-containing regimen. Trials are adding RAS inhibitors and vaccines to neoadjuvant chemotherapy and testing circulating tumour DNA to decide who should proceed to surgery.
State of the art
- Neoadjuvant chemotherapy is the standard for borderline disease, with modified FOLFIRINOX the usual regimen (PREOPANC, ESPAC-5).
- Venous resection and reconstruction is routine in high-volume centres and no longer a reason to call a tumour unresectable.
- The role of radiotherapy is being redefined after ALLIANCE A021501, with ablative and MR-guided techniques in trials.
- RAS inhibitors and vaccines are entering neoadjuvant trials for the first time.
Red cards
From the labels and guidelines behind the standard of care. Your team's thresholds win.- Emergency services nowBleeding or bruising
Bleeding that will not stop, black or bloody stools, or unexplained bruising when platelets are expected to be low.
- Emergency services nowBlood clot (lenalidomide, pomalidomide, thalidomide)
A swollen painful calf, or sudden breathlessness with chest pain; venous and arterial thromboembolism is a boxed warning and blood-thinning prophylaxis is recommended.
- Emergency services nowFainting or palpitations
Fainting, near-fainting, or an irregular or racing heartbeat; several kinase inhibitors prolong the QT interval and the labels require ECG and electrolyte monitoring.
See all on the product pages:CapecitabineDaraxonrasibFOLFIRINOX / mFOLFIRINOXGemcitabineGemcitabine + nab-paclitaxelNALIRIFOX (liposomal irinotecan + oxaliplatin + 5-FU/LV)·Printable cards in the navigator
Anatomy and lymph node drainage
- Pancreatic head (most PDAC)
- Body and tail
- Ampulla
- Islets (pancreatic NET)
- Intrahepatic ducts
- Perihilar (Klatskin)
- Distal bile duct
- Gallbladder
- Nodes: peripancreatic
- Nodes: hepatic hilar
- Nodes: coeliac and superior mesenteric
Most pancreatic cancers arise in the head next to the bile duct, which is why jaundice is the presenting sign; bile duct cancers are named by where along the tree they sit.
- Pancreatic head (most PDAC)Borderline resectable PDAC with venous involvement only (reconstructable portal or superior mesenteric vein) · Borderline resectable PDAC with limited arterial abutment (superior mesenteric or hepatic artery) · Biologically borderline PDAC (very high CA 19-9 or suspicious nodes with resectable anatomy) · Borderline resectable PDAC converted to resection after FOLFIRINOX · Borderline resectable PDAC that progresses during neoadjuvant therapy (treated as advanced disease)
- Body and tail
- Ampulla
- Islets (pancreatic NET)
- Intrahepatic ducts
- Perihilar (Klatskin)
- Distal bile duct
- Gallbladder
- peripancreatic
- hepatic hilar
- coeliac and superior mesenteric
Same organ: Pancreatic ductal adenocarcinoma, Biliary tract cancer (cholangiocarcinoma), Intrahepatic cholangiocarcinoma, Extrahepatic cholangiocarcinoma (perihilar and distal), Biliary tract cancer (all types), Neuroendocrine tumours, Pancreatic neuroendocrine tumours, Grade 3 well-differentiated neuroendocrine tumour, Extrapulmonary neuroendocrine carcinoma, Gallbladder cancer, Ampullary cancer (ampulla of Vater), Resectable pancreatic ductal adenocarcinoma, Locally advanced unresectable pancreatic ductal adenocarcinoma, Metastatic pancreatic ductal adenocarcinoma, KRAS G12C-mutant pancreatic ductal adenocarcinoma, KRAS wild-type pancreatic ductal adenocarcinoma, BRCA or PALB2-mutant pancreatic ductal adenocarcinoma, Mismatch repair deficient (MSI-high) pancreatic ductal adenocarcinoma, Pancreatic acinar cell carcinoma, Intraductal papillary mucinous neoplasm and other pancreatic cystic precursors, Pancreatoblastoma
A fifth or so of newly diagnosed pancreatic cancers touch a major vein or artery enough to make a clear-margin operation uncertain; how many are called borderline depends on the surgeon and the definition used.
- Liquid biopsy (ctDNA)Standard of care
Nothing recorded yet.
Nothing recorded yet.
Background: CA 19-9. Also on OnCo: Symptoms and red flags · Early detection roadmap.
Cases by country
No country-level case numbers. This cancer is not mapped to a GLOBOCAN site.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
Modified FOLFIRINOX for two to four months in fit patients, gemcitabine plus nab-paclitaxel otherwise; restage with CT and CA 19-9 before deciding on surgery (PREOPANC, ESPAC-5).
Optional; conventional chemoradiation or stereotactic radiotherapy to secure an arterial margin in selected patients, with ALLIANCE A021501 as the caution against routine use.
Pancreatoduodenectomy or distal pancreatectomy with venous resection and reconstruction where needed, arterial resection only in specialist centres; proceed on stable or improved disease with falling CA 19-9.
Complete six months of chemotherapy in total, usually with the regimen the tumour responded to.
Manage as locally advanced or metastatic disease; switch chemotherapy backbone, RAS inhibitor trials, biliary stenting for jaundice.
Subtypes & biomarkers
top- Borderline resectable PDAC with venous involvement only (reconstructable portal or superior mesenteric vein)
- Borderline resectable PDAC with limited arterial abutment (superior mesenteric or hepatic artery)
- Biologically borderline PDAC (very high CA 19-9 or suspicious nodes with resectable anatomy)
- Borderline resectable PDAC converted to resection after FOLFIRINOX
- Borderline resectable PDAC that progresses during neoadjuvant therapy (treated as advanced disease)
- Pancreas-protocol CT with degrees of vessel contact (defines the category)
- CA 19-9 trend during neoadjuvant chemotherapy (falling levels predict a useful operation)
- Restaging CT after chemotherapy (stable disease is acceptable; shrinkage is often modest)
- Germline BRCA1, BRCA2, PALB2 and ATM status (platinum choice)
- Pathological response grade and margin status after resection
- Circulating tumour DNA before surgery (investigational selection marker)
How often this target appears
- 2006MD Anderson defines borderline resectable disease by degrees of vessel contact
- 2011FOLFIRINOX proves active in metastatic disease and is taken up as a neoadjuvant regimen
- 2020PREOPANC-1: neoadjuvant chemoradiation improves clear-margin resection and long-term survival
- 2022ALLIANCE A021501: adding stereotactic radiotherapy to neoadjuvant FOLFIRINOX gives worse outcomes
- 2023ESPAC-5: neoadjuvant chemotherapy beats immediate surgery for borderline disease
- 2024PREOPANC-2: neoadjuvant FOLFIRINOX and gemcitabine chemoradiation give similar survival
Dated changes read from the records linked to this cancer: approvals, regulatory steps, reported trials, guideline versions and milestones. Newest first; no date is inferred.
All 9 changes by month →- 2026-09-18This recordBorderline resectable pancreatic ductal adenocarcinomaFacts on this page last checked
When this page itself was last checked or edited.
- 2024MilestonePREOPANC-1 / PREOPANC-2PREOPANC-2: neoadjuvant FOLFIRINOX and gemcitabine chemoradiation give similar survival
A milestone in how this cancer is treated.
- 2023MilestoneGemcitabineESPAC-5: neoadjuvant chemotherapy beats immediate surgery for borderline disease
A milestone in how this cancer is treated.
- 2022Trial resultPREOPANC-1 / PREOPANC-2PREOPANC-1 / PREOPANC-2 reported
PREOPANC-1 5-year OS 20.
- 2022MilestoneSBRT / SABR (stereotactic radiotherapy)ALLIANCE A021501: adding stereotactic radiotherapy to neoadjuvant FOLFIRINOX gives worse outcomes
A milestone in how this cancer is treated.
- 2020MilestonePREOPANC-1 / PREOPANC-2PREOPANC-1: neoadjuvant chemoradiation improves clear-margin resection and long-term survival
A milestone in how this cancer is treated.
What is in development for Borderline resectable pancreatic ductal adenocarcinoma, drawn from the whole corpus: 8 items. Drugs are grouped by the most advanced trial phase they have reached anywhere; approved treatments sit under standard of care. Technologies are the methods being tested for this cancer, trials are the studies recorded here, and ideas are proposals not yet in a trial.
Drugs in phase 2 · 1
Technologies being tested · 2
Trials under way · 2
- Study of Daraxonrasib (RMC-6236) in Patients With Resected Pancreatic Ductal Adenocarcinoma (PDAC) · phase 3 · Revolution Medicines, Inc.
- Initial Feasibility Study to Treat Borderline Resectable Pancreatic Cancer With a Planar LDR Source · phase 1/2 · CivaTech Oncology
Trials reported · 1
- PREOPANC-1 / PREOPANC-2 · phase 3 · 2022 · mixed
Ideas not yet in a trial · 2
Open problems and what is being done
Definitions of borderline disease differ between centres, so trial populations are not comparable.
CT underestimates response after chemotherapy, and there is no validated marker to tell fibrosis from viable tumour before surgery.
Whether radiotherapy adds anything after modern chemotherapy is unresolved.
Arterial resection carries high morbidity and its benefit is unproven outside expert centres.
and how the field plans to fix it →What is being done about thisSide effects and quality of lifeAvailable now- Cytotoxic chemotherapyStandard of care
- MR-guided adaptive radiotherapyEstablished
- Robotic & minimally invasive surgeryStandard of care
- SBRT / SABR (stereotactic radiotherapy)Standard of care
In trialsNothing recorded yet.
Ideas and roadmapsNothing recorded yet.
Also on OnCo: Side effects by symptom · Immune-related side effects · Toxicity compare · Survivorship planner.
Trials
topTrials recruiting now
Country and place are remembered in this browser only. A postcode is sent to OpenStreetMap's Nominatim service to find coordinates when you press the button; nothing else leaves your device.
Landmark trials
Expert centres
topExpert centres
Houston · cancer center | United States | 0 | 6,724 | 95,007 | #2 | ||
London · cancer center | United Kingdom | none recorded | 0 | 1,026 | 17,745 | #7 | |
Heidelberg · cancer center | Germany | none recorded | 0 | 3,456 | 45,745 | #18 | |
Seoul · hospital | South Korea | none recorded | 0 | 464 | 3,248 | #22 | |
Manchester · cancer center | United Kingdom | none recorded | 0 | 104 | 2,145 | #23 | |
Stanford · university | United States | 0 | 3,000 | 50,162 | #30 | ||
Amsterdam · cancer center | Netherlands | none recorded | 0 | 1,451 | 25,873 | #45 | |
Paris · consortium | France | none recorded | 1 | not matched | - | - | |
Shanghai · hospital | China | none recorded | 0 | 2,872 | 31,534 | - | |
Sydney · cancer center | Australia | none recorded | 0 | 2,222 | 33,278 | - | |
Amsterdam · hospital | Netherlands | none recorded | 0 | 2,104 | 25,115 | - | |
Los Angeles · cancer center | United States | 0 | 2,019 | 32,934 | - | ||
St. Louis, MO · cancer center | United States | 0 | 1,950 | 25,697 | - | ||
Beijing · hospital | China | none recorded | 0 | 1,784 | 18,230 | - | |
Dallas, TX · cancer center | United States | 0 | 1,744 | 19,757 | - |
These are the things we can measure; they are not a ranking of quality. Each column is a field on the institution record or a count over what OnCo has linked; a centre that treats many patients with Borderline resectable pancreatic ductal adenocarcinoma but is thinly recorded here will look small.
Not known: OnCo holds no case-volume or outcome figures for centres, so none are shown. Where a national audit or registry publishes them, the centre's page links to it. Default order: Newsweek rank, then trials for this cancer, then research output.
Questions to ask
topQuestions to ask your oncologist about Borderline resectable pancreatic ductal adenocarcinoma
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Why: Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Pancreas-protocol CT with degrees of vessel contact, CA 19-9 trend during neoadjuvant chemotherapy, Restaging CT after chemotherapy, Germline BRCA1, BRCA2, PALB2 and ATM status, Pathological response grade and margin status after resection), and what were the results?Why: These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Why: Recognised subtypes for this cancer include Borderline resectable PDAC with venous involvement only, Borderline resectable PDAC with limited arterial abutment, Biologically borderline PDAC.
- Is germline (inherited) genetic testing recommended for me or my family?Why: Inherited variants can change treatment and matter for relatives.
Neoadjuvant chemotherapy
- For my situation (neoadjuvant chemotherapy), which of the standard options do you recommend and why?Why: Guideline options include: Modified FOLFIRINOX for two to four months in fit patients, gemcitabine plus nab-paclitaxel otherwise; restage with CT and CA 19-9 before deciding on surgery (PREOPANC, ESPAC-5).
- Am I a candidate for FOLFIRINOX / mFOLFIRINOX, Gemcitabine + nab-paclitaxel, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of PREOPANC-1 / PREOPANC-2 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Radiotherapy after chemotherapy
- For my situation (radiotherapy after chemotherapy), which of the standard options do you recommend and why?Why: Guideline options include: Optional; conventional chemoradiation or stereotactic radiotherapy to secure an arterial margin in selected patients, with ALLIANCE A021501 as the caution against routine use.
- Am I a candidate for Capecitabine, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Surgery
- For my situation (surgery), which of the standard options do you recommend and why?Why: Guideline options include: Pancreatoduodenectomy or distal pancreatectomy with venous resection and reconstruction where needed, arterial resection only in specialist centres; proceed on stable or improved disease with falling CA 19-9.
After surgery
- For my situation (after surgery), which of the standard options do you recommend and why?Why: Guideline options include: Complete six months of chemotherapy in total, usually with the regimen the tumour responded to.
- Am I a candidate for FOLFIRINOX / mFOLFIRINOX, Gemcitabine + nab-paclitaxel, Gemcitabine or related drugs, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Progression during neoadjuvant therapy
- For my situation (progression during neoadjuvant therapy), which of the standard options do you recommend and why?Why: Guideline options include: Manage as locally advanced or metastatic disease; switch chemotherapy backbone, RAS inhibitor trials, biliary stenting for jaundice.
- Am I a candidate for NALIRIFOX (liposomal irinotecan + oxaliplatin + 5-FU/LV), Daraxonrasib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Any stage
- Are there clinical trials I could join, for example of Study of Daraxonrasib (RMC-6236) in Patients With Resected Pancreatic Ductal Adenocarcinoma (PDAC), Initial Feasibility Study to Treat Borderline Resectable Pancreatic Cancer With a Planar LDR Source, Daraxonrasib, Autogene cevumeran?Why: Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Why: Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Why: Supportive care improves quality of life and helps patients complete treatment.
- I read that “Definitions of borderline disease differ between centres, so trial populations are not comparable”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
- I read that “CT underestimates response after chemotherapy, and there is no validated marker to tell fibrosis from viable tumour before surgery”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
Newly diagnosed? Read the first 60 days with Borderline resectable pancreatic ductal adenocarcinoma, then print the one-page appointment sheet with room for the answers.
Print this page for your appointment (your browser's print command). These prompts are for discussion; your clinical team knows your case.
Direct links plus the targets, companies, and technologies of this cancer's products.
technologies
13targets
2drugs
7companies
5pathways
2terms
9trials
4ideas
2people
6key papers
1Latest papers
topQuery for this cancer: (TITLE:"Borderline resectable pancreatic ductal adenocarcinoma" OR ABSTRACT:"Borderline resectable pancreatic ductal adenocarcinoma" OR TITLE:"Borderline resectable pancreatic cancer" OR ABSTRACT:"Borderline resectable pancreatic cancer" OR TITLE:"BRPC" OR ABSTRACT:"BRPC" OR TITLE:"Marginally resectable pancreatic cancer" OR ABSTRACT:"Marginally resectable pancreatic cancer") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Borderline resectable pancreatic ductal adenocarcinoma, not a curated reading list.
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