Skip to main contentLast updated: 09-Nov-2026
Dr Harsh Shah
MS, MCh (Surgical Gastroenterology), DrNB (Surgical Gastroenterology)
Registered with Gujarat Medical Council, Reg. No. G-38738
Pancreas Cancer Surgeon
Dr. Jivraj Mehta Hospital, Vasna, Ahmedabad · 18 years of experience
In short
Doctors use two systems. The TNM stage says how far the cancer has spread. The resectability group says whether surgery can remove it safely now.
Resectable means the main blood vessels are clear. Borderline means the tumour touches a vessel, so chemotherapy usually comes first. Locally advanced means the vessels are too involved to operate now.
A pancreas-protocol CT scan and a team review decide the group. The group can change after chemotherapy.
This post explains how pancreatic cancer is staged and judged for surgery. For the whole treatment pathway, see our pancreatic cancer treatment page.
Each system answers a different question. TNM asks how advanced the cancer is. Resectability asks whether an operation can take it all out today.
| System | Question it answers | Who relies on it |
|---|---|---|
| TNM stage (AJCC, 8th edition) | How big is the tumour, are nodes involved, has it spread? | Pathologist and oncologist, for the final stage and outlook |
| Resectability group (NCCN) | Does the tumour touch the main vessels, so can it be removed safely now? | Surgeon and tumour board, before any treatment starts |
The two usually point the same way, but they are not the same thing. A small tumour can wrap around an artery, so its TNM stage looks early while it cannot be operated on. For planning, the resectability group is the one that matters most, because it decides the order of treatment. Our post on which tests are done for pancreatic cancer, and in what order shows how the scans that feed both systems are chosen.
T is the size and reach of the tumour. N is the number of nearby lymph nodes with cancer. M says whether it has spread to a distant organ.
| Letter | Grade | Plain meaning |
|---|---|---|
| T1 | Up to 2 cm | Small tumour inside the pancreas |
| T2 | More than 2 cm, up to 4 cm | Medium tumour inside the pancreas |
| T3 | More than 4 cm | Large tumour, still no main artery involved |
| T4 | Any size | The coeliac artery, the superior mesenteric artery or the common hepatic artery is involved |
| N0 / N1 / N2 | None / one to three / four or more | Regional lymph nodes holding cancer |
| M0 / M1 | No spread / spread | M1 includes liver, lung, lining of the belly and far-away nodes |
At least twelve lymph nodes should be removed and examined at operation. A smaller number can miss cancer and make the stage look better than it is.
The three letters combine into a stage from I to IV.
The difference is how much the tumour touches the main arteries and veins beside the pancreas. A vein can often be cut and rebuilt. An artery rarely can.
| Group | Artery contact | Vein contact | Plain meaning |
|---|---|---|---|
| Resectable | None | Less than half the circle of the vein, with a smooth edge | Surgery can be done first |
| Borderline | Less than half the circle of the superior mesenteric or coeliac artery, or the hepatic artery in a segment that can be rebuilt | More than half the circle, an uneven edge, or a clot, but the vein can still be rebuilt | Chemotherapy first, then a fresh look |
| Locally advanced | More than half the circle of the superior mesenteric or coeliac artery | Vein cannot be rebuilt | Chemotherapy first. Surgery only if the tumour shrinks away from the vessels |
| Metastatic | Cancer in the liver, lung, belly lining or distant nodes | Chemotherapy to control it | |
“Half the circle” means 180 degrees around the vessel on the CT slices. These are strict lines drawn by radiologists and surgeons together. A tumour that touches by a few degrees less or more can fall into a different group, which is why a second reading of the scan is often useful.
A Whipple operation must remove the tumour with a rim of healthy tissue all round. Vessels run right beside the pancreas, so a tumour on a vessel wall is the commonest reason that rim is missed.
The key vessels are the superior mesenteric artery, the coeliac artery and the hepatic artery, which feed the gut and liver. The superior mesenteric vein and the portal vein carry blood back from the gut. A surgeon can join a vein end to end or patch it. An artery that is wrapped for most of its circle cannot be stripped safely, because cutting it risks the blood supply to the bowel or liver.
Radiologists often describe how the tumour meets a vein. These descriptions help to judge how hard the repair will be.
No. Some centres use three kinds of borderline: by anatomy, by tumour biology and by fitness. A tumour can be borderline even when the scan looks clear.
| Kind | What makes it borderline |
|---|---|
| Anatomical | Vessel contact on the scan, as in the table above |
| Biological | A very high CA 19-9 blood level (above 500 units per mL), suggesting hidden spread |
| Conditional | Poor general fitness, so a big operation is risky until the patient is stronger |
These labels guide whether chemotherapy before surgery is a must or a choice. A very high CA 19-9 in a tumour that looks removable is a warning that cancer cells may already have left the pancreas, so many teams give chemotherapy first.
The group sets the order of treatment. Resectable cancers can go to surgery first. Borderline and locally advanced cancers usually start with chemotherapy.
| Group | Usual plan |
|---|---|
| Resectable | Whipple operation (head) or removal of the tail (body and tail), then chemotherapy. Some centres give chemotherapy first. |
| Borderline | Chemotherapy first, often FOLFIRINOX for about six cycles. Re-scan, then operate if a clear margin now looks likely. |
| Locally advanced | Chemotherapy for six to eight cycles, then re-scan. A minority of tumours shrink enough for surgery. |
| Metastatic | Chemotherapy and supportive care. Surgery is rarely part of the plan. |
None of this means a borderline or locally advanced cancer is hopeless. Chemotherapy first treats hidden cells early and lets the team see how the tumour behaves before a major operation. A tumour that responds is a better candidate for surgery. One that grows quickly is spared an operation that would not have helped.
After chemotherapy the tumour is scanned again and the group is reassessed. The scan often looks unchanged even when the cancer has responded, so other signs are weighed too.
The pathologist adds the letters “yp” before the stage when the specimen comes after chemotherapy, for example ypT2. The tumour is also graded on how many cancer cells remain. Few cancers disappear completely. After chemotherapy, the surgical team decides on response and judgement, because the scan rules for the first assessment no longer apply neatly.
The margin tells whether cancer cells reach the cut edge of the specimen. A clear margin is called R0 and is the goal of every operation.
| Code | Meaning |
|---|---|
| R0 | Cancer is at least 1 mm away from every cut edge |
| R1 | Cancer cells are within 1 mm of an edge, seen only under the microscope |
| R2 | Tumour left behind that can be seen |
Several edges are checked: the front and back surfaces, the vein and artery edges, the bile duct, the pancreatic neck and the tissue behind the bowel. The report also lists how many nodes were removed, whether cancer is in the small nerves or blood vessels, and the response grade after chemotherapy. If you are unsure what your report says, our post on what the pancreas biopsy report and gene tests mean explains the wording.
Staging is only as good as the scan and the team reading it. A pancreas-protocol CT, read by a team that sees many pancreatic cancers, gives the most reliable group.
Stage (TNM) says how far the cancer has spread. Resectability says whether surgery can remove it safely now, based on how much the tumour touches the main blood vessels.
The tumour touches a major vein or artery, but not so much that surgery is impossible. Chemotherapy is usually given first, then the scan is repeated before a decision on surgery.
The tumour wraps around a main artery or a vein that cannot be rebuilt, but it has not spread to distant organs. Chemotherapy comes first. A minority of tumours shrink enough for surgery.
Sometimes. After several cycles of chemotherapy, the scan, the CA 19-9 level and the patient's health are reviewed. If the tumour has moved away from the vessels, surgery can be planned.
It treats hidden cancer cells early, may shrink the tumour away from vessels, and shows how the cancer behaves. A tumour that grows fast is spared an operation that would not have helped.
Not by itself. A very high level can mean hidden spread, so many teams give chemotherapy first. Jaundice can also raise CA 19-9, so it is read after the bile duct is drained.
R0 means no cancer cells reach the cut edge of the removed specimen, and the nearest cancer is at least 1 mm away. It is the aim of every cancer operation.
Yes. Bring the CT or MRI films and the reports. A second reading by a team that sees many pancreatic cancers can confirm the group or show that the tumour is more removable than first thought.
For the whole treatment pathway, start at the pancreatic cancer treatment page. For questions before you travel, call +91-63555-64601.
Dr Harsh Shah — Dr. Jivraj Mehta Hospital, Vasna, Ahmedabad
Dr. Jivraj Mehta Hospital, Dr Jivraj Mehta Marg, Vasna, Ahmedabad 380007.
Consultations, review of reports and scans, operations and follow-up. OPD Monday to Saturday, 9 am to 5 pm.
Appointments: +91-63555-64601 · +91-63590-11009 · Hospital 079-2663 6363
Directions to the hospital · WhatsApp +91-63555-64601
Been told your pancreatic cancer is "borderline" or "locally advanced" and not sure what that means for surgery? Dr Harsh Shah reads your scans with you and explains which group you fall in and why. Bring your CT or MRI films and reports. You can also call, or message us on WhatsApp. Call For Appointment Book on WhatsApp Tapping Book on WhatsApp will likely open the WhatsApp app on your phone.
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