PDAC resectability Pancreatic ductal adenocarcinoma anatomic resectability classification

{
  "categories": [
    {
      "outcome_code": "resectable",
      "anatomic_meaning": "no_disqualifying_major_arterial_contact_and_no_deforming_or_unreconstructible_major_venous_involvement_under_the_named_criteria_version",
      "metastatic_state": "no_distant_metastasis_identified"
    },
    {
      "outcome_code": "borderline-resectable",
      "anatomic_meaning": "limited_major_arterial_contact_or_reconstructible_major_venous_involvement_under_the_named_criteria_version",
      "metastatic_state": "no_distant_metastasis_identified"
    },
    {
      "outcome_code": "locally-advanced",
      "anatomic_meaning": "nonmetastatic_extensive_arterial_involvement_or_unreconstructible_major_venous_involvement_under_the_named_criteria_version",
      "metastatic_state": "no_distant_metastasis_identified"
    },
    {
      "outcome_code": "metastatic",
      "anatomic_meaning": "distant_metastatic_disease_M1_is_present",
      "local_vascular_category": "retain_as_a_separate_descriptor_when_useful_but_M1_takes_priority_in_the_four_label_output"
    }
  ],
  "applicability": {
    "use_for": "Initial staging or explicitly time-stamped restaging of suspected or confirmed pancreatic ductal adenocarcinoma using dedicated pancreas imaging and a named resectability convention.",
    "classification_unit": "one_patient_at_one_treatment_timepoint_with_local_anatomic_and_distant_disease_components_recorded_separately",
    "required_inputs": [
      "imaging_date_and_pretreatment_or_post_neoadjuvant_state",
      "dedicated_pancreas_protocol_CT_or_reason_for_alternative",
      "tumor_location_and_dimensions",
      "arterial_contact_by_named_vessel",
      "venous_contact_by_named_vessel",
      "degree_length_contour_and_patency_of_contact",
      "variant_vascular_anatomy",
      "reconstructibility_assessment_or_explicit_unknown",
      "distant_metastasis_assessment",
      "indeterminate_lesions",
      "criteria_version_and_treating_center_convention"
    ],
    "outside_scope": [
      "pancreatic_neuroendocrine_tumor_or_cystic_neoplasm",
      "AJCC_TNM_stage_substitution",
      "pathologic_confirmation",
      "automatic_operability_or_fitness_decision",
      "automatic_selection_of_upfront_resection_neoadjuvant_therapy_radiotherapy_or_palliation",
      "prediction_of_R0_resection_or_survival_from_label_alone"
    ]
  },
  "imaging_and_quality_gate": {
    "preferred_initial_test": "High-quality multidetector pancreas-protocol CT with thin sections, pancreatic parenchymal and portal venous phases, multiplanar and vascular reconstructions, and chest or other distant staging according to the clinical pathway.",
    "problem_solving": "MRI with diffusion-weighted imaging is useful for an occult or isoattenuating primary and indeterminate liver lesions; PET/CT is selective rather than a replacement for complete anatomic staging.",
    "quality_failure_rule": "If phase timing, motion, slice thickness, field of view or incomplete distant staging prevents confident assessment, return technically limited and list the missing vessel or metastatic territory rather than assign a falsely definitive category.",
    "pathology_guard": "Imaging can state a PDAC-like mass and anatomic category, but it cannot establish histology; preserve whether tissue diagnosis is confirmed, pending or not available."
  },
  "observation_vector_before_category": {
    "primary_tumor": [
      "head_uncinate_neck_body_or_tail",
      "three_dimensions",
      "enhancement_and_visibility",
      "pancreatic_and_bile_duct_caliber_and_cutoff",
      "upstream_atrophy",
      "pancreatitis_or_collection",
      "duodenal_stomach_colon_spleen_adrenal_or_other_direct_extension"
    ],
    "arteries_each_separate": [
      "celiac_axis",
      "common_hepatic_artery",
      "proper_hepatic_and_bifurcation_when_relevant",
      "superior_mesenteric_artery",
      "gastroduodenal_artery",
      "aorta",
      "variant_or_replaced_hepatic_arteries",
      "first_jejunal_or_colic_branches_when_relevant"
    ],
    "veins_each_separate": [
      "portal_vein",
      "superior_mesenteric_vein",
      "portal_SMV_confluence",
      "splenic_vein",
      "inferior_vena_cava",
      "jejunal_or_colic_tributaries_when_relevant"
    ],
    "contact_attributes": [
      "no_contact_or_interface",
      "degrees_of_circumferential_contact",
      "longitudinal_contact_mm",
      "narrowing_or_contour_irregularity",
      "occlusion",
      "tumor_or_bland_thrombosis",
      "collateral_formation",
      "proximal_and_distal_venous_segments",
      "reconstructible_yes_no_or_unknown_by_MDT"
    ],
    "distant_and_regional": [
      "liver",
      "peritoneum_and_omentum",
      "lungs",
      "nonregional_nodes",
      "bone_and_other_sites_when_visible",
      "regional_nodes_described_separately_from_M1",
      "ascites",
      "each_indeterminate_lesion_with_recommended_problem_solving"
    ],
    "surgical_planning_context": [
      "arterial_variants",
      "celiac_or_SMA_origin_stenosis_and_cause",
      "relationship_to_GDA_and_hepatic_bifurcation",
      "venous_collaterals",
      "prior_bypass_stent_or_other_intervention"
    ]
  },
  "terminology_and_version_gate": {
    "contact": "Report degrees rather than relying on contact alone.",
    "abutment": "Commonly means contact of 180 degrees or less, but the report must preserve the measured range because published and institutional definitions vary.",
    "encasement": "Commonly means contact greater than 180 degrees; narrowing or contour deformity can add concern but must be reported rather than silently substituted for degrees.",
    "reconstructibility": "Reconstructibility is not a CT fact alone. Describe proximal and distal targets, length, occlusion and collaterals, then record the pancreatic surgical MDT judgment or unknown.",
    "version_rule": "NCCN, MD Anderson, Alliance, ISGPS and institutional maps differ, and current criteria can change. Store the objective vector and named version so a new map can be reapplied without reinterpreting the images."
  },
  "detailed_NCCN_style_map_reported_in_2023_review": {
    "resectable": {
      "arterial": "No solid tumor contact with CA, SMA or CHA.",
      "venous": "No SMV or PV contact, or contact of 180 degrees or less without contour irregularity."
    },
    "borderline_resectable": {
      "head_or_uncinate_arterial": [
        "CHA_contact_without_extension_to_CA_or_hepatic_artery_bifurcation",
        "SMA_contact_180_degrees_or_less",
        "contact_with_variant_arterial_anatomy_when_reconstructive_implications_are_documented"
      ],
      "body_or_tail_arterial": [
        "CA_contact_180_degrees_or_less"
      ],
      "venous": [
        "SMV_or_PV_contact_greater_than_180_degrees_if_reconstructible",
        "SMV_or_PV_contact_180_degrees_or_less_with_contour_irregularity_if_reconstructible",
        "SMV_or_PV_thrombosis_if_suitable_proximal_and_distal_vessel_allows_reconstruction"
      ]
    },
    "locally_advanced": {
      "arterial": [
        "SMA_or_CA_contact_greater_than_180_degrees",
        "body_or_tail_CA_involvement_extending_to_the_aorta",
        "other_extensive_major_arterial_involvement_outside_the_borderline_map"
      ],
      "venous": [
        "SMV_or_PV_involvement_or_occlusion_not_reconstructible"
      ]
    },
    "source_boundary": "This detailed threshold map is reproduced in the 2023 Chu and Fishman review from then-current NCCN criteria. It must not be presented as timeless or substituted for the treating center's current named version."
  },
  "NCCN_v2_2025_summary_reported_in_2026_review": {
    "resectable": "No contact with major arteries and no major-vein contact, or venous abutment without deformity.",
    "borderline_resectable": "Reconstructible PV, SMV or IVC abutment with deformity or encasement; head tumors with abutment of common or variant hepatic artery or SMA; body or tail tumors with CA abutment.",
    "locally_advanced": "Extensive unreconstructible venous involvement; major-arterial encasement; CA involvement extending to aorta; or hepatic-artery involvement extending to CA or hepatic bifurcation.",
    "interpretation_rule": "When a concise current summary and an older degree-based table appear discordant, return the measurements and named convention; do not manufacture a universal equivalence."
  },
  "classification_algorithm": [
    {
      "priority": 1,
      "if": "definite_distant_metastasis_M1",
      "output_code": "metastatic",
      "retain": "local_anatomic_vector_and_indeterminate_or_confirmed_basis"
    },
    {
      "priority": 2,
      "if": "no_M1_AND_unreconstructible_major_venous_involvement_or_major_arterial_involvement_meets_named_locally_advanced_map",
      "output_code": "locally-advanced"
    },
    {
      "priority": 3,
      "if": "no_M1_AND_limited_arterial_or_reconstructible_venous_involvement_meets_named_borderline_map",
      "output_code": "borderline-resectable"
    },
    {
      "priority": 4,
      "if": "no_M1_AND_all_required_arterial_and_venous_features_meet_named_resectable_map",
      "output_code": "resectable"
    },
    {
      "priority": 5,
      "if": "a_decisive_metastatic_lesion_vessel_measurement_or_reconstructibility_judgment_is_missing_or_version_dependent",
      "output": "indeterminate_resectability_with_explicit_missing_or_conflicting_feature"
    }
  ],
  "metastatic_and_indeterminate_lesion_boundary": {
    "M1_rule": "Use metastatic only for imaging or pathology sufficiently convincing for distant disease under the case standard; name the site and evidentiary basis.",
    "indeterminate_rule": "A tiny indeterminate liver, lung, peritoneal or nodal finding must remain indeterminate and trigger appropriate MRI, short-interval comparison, PET/CT, biopsy or staging procedure consideration rather than automatic M1 assignment.",
    "nodal_rule": "Regional nodes contribute to N stage, not this local vascular label; nonregional nodes can be M1. Size and morphology alone are imperfect, so preserve confidence."
  },
  "anatomic_biologic_conditional_model": {
    "anatomic_A": "The four labels summarize anatomic distribution under a named convention.",
    "biologic_B": "CA 19-9, suspicious nodes, occult-metastatic risk, tumor phenotype, germline and somatic findings can affect strategy but do not rewrite vessel contact. CA 19-9 is nonspecific in biliary obstruction and can be falsely low in Lewis-antigen nonsecretors.",
    "conditional_C": "Performance status, frailty, nutrition, comorbidity, symptoms, patient goals and center expertise affect operability and therapy selection but are not visible in the anatomic label.",
    "agent_rule": "Return A, B and C as separate evidence domains. Never infer biologic fitness or patient preference from CT."
  },
  "post_neoadjuvant_restaging_boundary": {
    "comparison_required": "Record regimen, dates and baseline examination; compare primary size, attenuation, vessel contact, deformity, metastases and CA 19-9 context when supplied.",
    "fibrosis_guard": "Persistent perivascular soft tissue after neoadjuvant therapy may represent fibrosis and can overestimate viable vascular invasion; lack of dramatic shrinkage does not by itself prove treatment failure or unresectability.",
    "progression_guard": "New definite metastasis or unequivocal local progression is different from stable residual contact. Indeterminate new findings remain indeterminate until resolved.",
    "MDT_rule": "Post-treatment exploration or continued therapy is a multidisciplinary decision at an experienced center; do not mechanically reuse the pretreatment category as an operation order."
  },
  "management_boundary_by_category": {
    "resectable": "Both upfront resection with systemic-therapy planning and neoadjuvant approaches can be valid in selected patients. The label alone does not choose between them or establish technical or physiologic operability.",
    "borderline_resectable": "Neoadjuvant systemic therapy is commonly considered and restaging is expected, but regimen, radiation, exploration and reconstruction depend on pathology, biology, performance status, response and expert MDT review.",
    "locally_advanced": "Systemic therapy is commonly the initial backbone; selected patients may undergo local therapy or conversion evaluation after response. Locally advanced at one timepoint does not mean permanently or biologically unresectable.",
    "metastatic": "Management is systemic and goal-directed in most cases, with molecular or germline evaluation and symptom-directed procedures when appropriate. The radiologic label does not prescribe a regimen, prove futility or replace goals-of-care discussion.",
    "universal_rule": "No category autonomously orders or denies surgery, chemotherapy, radiotherapy, biliary drainage, biopsy, anticoagulation or palliative care."
  },
  "risk_and_prognosis_boundary": {
    "anatomic_signal": "Increasing vascular involvement generally lowers the probability of a margin-negative resection in historical cohorts, while M1 denotes systemic spread; this is a group-level relation, not an individual probability.",
    "recurrence_guard": "Even anatomically resectable and R0-resected PDAC can recur. Do not describe resectable as low risk or cured.",
    "no_fixed_survival": "Do not attach a fixed survival, R0 rate or response probability to a category without the exact cohort, era, treatment, biology and patient condition."
  },
  "agent_output_contract": [
    "Return imaging date, initial versus post-neoadjuvant state, technical adequacy and the exact named criteria version or local convention.",
    "Return the complete per-vessel observation vector before the category, including degrees, millimetres, deformity, patency, thrombosis, collaterals, variant anatomy and reconstructibility source.",
    "Return tumor site and dimensions, regional disease, every definite metastatic site and every unresolved indeterminate lesion separately.",
    "Return one supported category or explicit version-dependent/indeterminate resectability with the decisive feature.",
    "Keep anatomic category, TNM, pathology, biologic risk, performance/fitness and MDT treatment recommendation in distinct fields.",
    "For post-neoadjuvant studies, preserve baseline comparison and fibrosis uncertainty rather than equating residual contact with viable unresectable tumor.",
    "Never convert resectable to automatic surgery, borderline to mandatory neoadjuvant therapy, locally advanced to permanent nonoperability, or metastatic to a statement of futility."
  ],
  "missing_input_behavior": [
    "If dedicated pancreas phases are absent or a decisive vessel is not assessable, report incomplete staging and do not force a category.",
    "If contact is described only as abutment or encasement without degrees, length or contour, preserve the word and request or return the missing measurement.",
    "If reconstructibility is unknown, report the objective venous anatomy and mark category as pending pancreatic surgical review where it changes the branch.",
    "If a distant lesion is indeterminate, do not call M1 or nonmetastatic with false certainty.",
    "If the criteria version is unknown and published maps disagree, return the raw vector plus the possible categories under each named map.",
    "If pathology is unavailable, say suspected PDAC rather than confirmed PDAC."
  ],
  "supporting_sources": [
    {
      "role": "current_NCCN_v2_2025_imaging_review",
      "citation": "Lee et al. Korean J Radiol. 2026;27:634",
      "doi": "10.3348/kjr.2026.0341",
      "pmcid": "PMC13333231"
    },
    {
      "role": "degree_based_NCCN_and_Alliance_comparison",
      "citation": "Chu and Fishman. Int J Surg. 2023",
      "doi": "10.1097/JS9.0000000000000899",
      "pmcid": "PMC11486980"
    },
    {
      "role": "structured_reporting_consensus",
      "citation": "Al-Hawary et al. Radiology. 2014;270:248-260",
      "doi": "10.1148/radiol.13131184",
      "pmid": "24354378"
    },
    {
      "role": "objective_vector_and_MDT_boundary",
      "citation": "Moir et al. BMJ Oncol. 2023;2:e000055",
      "doi": "10.1136/bmjonc-2023-000055",
      "pmcid": "PMC11203077"
    },
    {
      "role": "current_imaging_appropriateness",
      "citation": "ACR Appropriateness Criteria. Revised 2025",
      "url": "https://acsearch.acr.org/docs/3099847/Narrative"
    }
  ],
  "source_locator": "Lee et al. 2026, PMC13333231, Table 1 and sections on biologic/conditional resectability and post-NAT restaging; Chu and Fishman 2023, PMC11486980, Table 1 detailed NCCN and Alliance thresholds; Al-Hawary et al. 2014, DOI 10.1148/radiol.13131184, consensus reporting template; Moir et al. 2023, PMC11203077, vessel-level PACT-UK template and explicit center/MDT resectability boundary; ACR revised 2025 narrative for current modality appropriateness."
}