Pancreatic ductal adenocrcinoma is defined locally advanced (stage III) when has spread to the superior mesenteric artery and/or to the celiac trunk. Adenocarcinoma of the pancreatic head usually spreads to the superior mesenteric artery, that supplies with oxygen-rich bood the intestine; tumors of the body-tail of the pancreas spread more often to the celiac trunk, whose branches supply the liver, the stomach and the spleen. For more information about the anatomy of peripancreatic vessels click here.  

When cross-sectional imaging reveals a locally advanced pancreatic ductal adenocarcinoma, it is necessary to obtain a pathologic diagnosis (usually cytologic). The procedure used most often to diagnose pancreatic ductal adenocarcinoma is called a fine needle aspiration biopsy. For this test, a thin needle is inserted through the skin and into the pancreas. Ultrasonography is used to look at the position of the needle and make sure that it is in the tumor. Biopsies can be also performed using endoscopic ultrasound, placing the needle directly through the wall of the stomach or through the duodenum into the tumor. In either case, small tissue samples can be removed through the needle. Tissue samples are then examined under a microscope. The abnormal cells are found and examined by the Pathologist, who decides on a diagnosis. 

If the neoplasm has caused symptoms, a palliative treatment may be necessary to relieve them:

• A plastic or metal stent can be placed endoscopically to relieve the jaundice caused by blocked common bile duct. This is very common in pancreatic head neoplasms. Alternatively, a percutaneous biliary drainage may be placed. For more information click here. 
• If necessary, surgery can reroute the flow of bile from the common bile duct directly into the small intestine, bypassing the pancreas (bypass operation). The stomach connection to the duodenum can be rerouted at this time as well to relieve or prevent duodenal obstruction. Furthermore, intraoperative biopsies may be performed. 

The first-line treatment of locally advanced pancreatic ductal adenocarcinoma is medical therapy. Chemotherapy involves the use of medications to kill cancer cells, and may be given intravenously or by mouth. These drugs are usually given in cycles, with alternating periods of treatment and recovery, and may be given alone or in conjunction with radiation therapy (chemo-radiotherapy). The Oncology team chooses the best treatment plan for any given patient. Once the treatment schedule has been completed, re-staging is performed. This involves a detailed clinical examination, the measurement of serum Ca 19.9, and cross-sectional imaging (CT-scan or PET-CT). The results are discussed within our multidisciplinary team. Outcomes after first-line medical treatment for locally advanced pancreatic ductal adenocarcinoma include:  

• Disease regression (down-staging). This means that the disease has become resectable, at least on the basis of cross-sectional imaging. The Surgeon may decide for surgical exploration, if it is likely the neoplasm can be completely removed surgically. Thanks to new chemotherapy regimens, pancreatic resections performed after disease downstaging are increasingly being reported. 
• Stable disease. This means that no new tumors have developed, and that the neoplasm has not spread to any new regions of the body (in other words, the neoplasm is not getting better or worse). In such a situation, the management is tailored to the single patient, after multidisciplinary discussion. Additional chemotherapy or chemo-radiotherapy may be advised, as well as the inclusion into experimental protocols, including radiofrequency ablation. To learn more about radiofrequency ablation click here.
• Disease progression. This means that the tumor has progressed locally (has grown in size) or has spread to other organs of the body (has metastasized). The most common metastatic site is the liver. In such a situation, second-line chemotherapy may be indicated, as well as the inclusion into experimental clinical trials. Radiofrequency ablation may be advised in non-metastatic disease. For more information about metastatic pancreatic ductal adenocarcinoma click here.