Contemporary Management of Borderline Resectable and Locally Advanced Unresectable Pancreatic Cancer

Abstract

Adenocarcinoma of the pancreas remains a highly lethal disease, with less than 5% survival at 5 years. Borderline resectable pancreatic cancer (BRPC) and locally advanced unresectable pancreatic cancer (LAPC) account for approximately 30% of newly diagnosed cases of PC. The objective of BRPC therapy is to downstage the tumor to allow resection; the objective of LAPC therapy is to control disease and improve survival. There is no consensus on the definitions of BRPC and LAPC, which leads to major limitations in designing clinical trials and evaluating their results. A multimodality approach is always needed to ensure proper utilization and timing of chemotherapy, radiation, and surgery in the management of this disease. Combination chemotherapy regimens (5-fluorouracil, leucovorin, irinotecan, oxaliplatin, and gemcitabine [FOLFIRINOX] and gemcitabine/nab-paclitaxel) have improved overall survival in metastatic disease. The role of combination chemotherapy regimens in BRPC and LAPC is an area of active investigation. There is no consensus on the dose, modality, and role of radiation therapy in the treatment of BRPC and LAPC. This article reviews the literature and highlights the areas of controversy regarding management of BRPC and LAPC. The Oncologist 2016;21:178-187 Implications for Practice: Pancreatic cancer is one of the worst cancers with regard to survival, even at early stages of the disease. This review evaluates all the evidence for the stages in which the cancer is not primarily resectable with surgery, known as borderline resectable or locally advanced unresectable. Recently, advancements in radiation techniques and use of better combination chemotherapies have improved survival and tolerance. There is no consensus on description of stages or treatment sequences (chemotherapy, chemoradiation, radiation), nor on the best chemotherapy regimen. The evidence behind the treatment paradigm for these stages of pancreatic cancer is summarized.

Are there still indications for total pancreatectomy?

“…Even if the surgical treatment of locally advanced pancreatic cancer is currently not the standard of care, it did receive more attention recently in the light of the more promising results of new neoadjuvant treatments [43]. In selected cases, surgery for locally advanced pancreatic cancer is also supported by the international scientific community [44].…”

Comparison of endoscopic ultrasound tissue acquisition methods for genomic analysis of pancreatic cancer

“…Endoscopic ultrasonography with tissue acquisition (EUS‐TA) via fine needle aspiration (FNA) or fine needle biopsy (FNB) is the preferred modality for diagnosing and staging pancreatic ductal adenocarcinoma (PDAC). A larger percentage of patients with borderline or locally advanced disease are undergoing neoadjuvant therapy before surgery . Therefore, EUS‐TA represents an ideal modality for obtaining tissue for genomic profiling to allow for targeted therapy at the time of diagnosis.…”

Pancreatic cancer: treatment approaches and trends

“…Cancer that is confined to the pancreas but involves nearby blood vessels or structures to a greater extent is called borderline resectable [23] . Cancer that involves nearby blood vessels or other structures to such a significant extent that it cannot be successfully removed by surgery is called locally advanced nonresectable [24] . Cancer that has spread outside the pancreas to other organs and tissues in the body is called metastatic.…”