Tumor-vessel relationships in pancreatic ductal adenocarcinoma at multidetector CT: Different classification systems and their influence on treatment planning

Treatment of pancreatic ductal adenocarcinoma (PDAC) remains a challenge, given its propensity for early systemic spread and growth into the adjacent vital vascular structures. With the advent of newer surgical techniques and chemoradiation therapies, multidetector computed tomography (CT) plays a crucial role in the identification of patients with borderline resectable disease who may benefit from such treatments. Stage III PDAC is divided into two categories-locally advanced, defined by arterial encasement or nonreconstructible portovenous axis involvement; and borderline resectable, defined by limited arterial involvement and/or reconstructible portovenous involvement. A consensus definition for stage III borderline resectable PDAC has been proposed by the Americas Hepato-Pancreato-Biliary Association, the Society of Surgical Oncology, and the Society for Surgery of the Alimentary Tract and has gained widespread use. Evaluation of borderline resectable disease involves the identification of the circumferential and longitudinal relationship of the tumor with its neighboring vessels, markers of vascular invasion, and aberrant anatomic structures that alter the surgical approach. Furthermore, the use of template-based radiology reporting may increase the objectivity of the evaluation and mandate the provision of all of the key descriptors required for a comprehensive evaluation of the disease. In this review, the staging of PDAC at multidetector CT is described, with reference to the evaluation of the tumor-vessel interface as it guides treatment planning, along with a discussion of the key descriptors of PDAC at multidetector CT and their importance. Examples are provided of the imaging findings of borderline resectable disease and different surgical approaches, along with a discussion on the importance of standardized terminology and template-based reporting.