Neoadjuvant Treatment for Borderline Resectable Pancreatic Ductal Adenocarcinoma

Abstract

One of the main reasons for the dismal prognosis of pancreatic ductal adenocarcinoma (PDAC) is its late diagnosis. At the time of presentation, only approximately 15–20% of all patients with PDAC are considered resectable and around 30% are considered borderline resectable. A surgical approach, which is the only curative option, is limited in borderline resectable patients by local involvement of surrounding structures. In borderline resectable pancreatic cancer (BRPC), neoadjuvant treatment regimens have been introduced with the rationale to downstage and downsize the tumor in order to enable resection and eliminate ­microscopic distant metastases. However, there are no official guidelines for the preoperative treatment of BRPC. In the majority of cases, patients are administered ­Gemcitabine-based or FOLFIRINOX-based chemotherapy regimens with or without radiation. Radiologic restaging after neoadjuvant therapy has to be judged with caution when it comes to predict tumor response and resectability, since inflammation induced by neoadjuvant therapy may mimic solid tumor. Patients who do not show any disease progression during neoadjuvant therapy should be offered surgical exploration, since a high percentage is likely to undergo resection with negative margins (R0) and, thus, achieve improved overall survival although imaging judged it unlikely. Despite the promising new approaches of neoadjuvant treatment regimens during the last 2 decades, surgery remains the first choice if the tumor appears to be primary resectable at the time of diagnosis. At present, there are no international guidelines regarding the preoperative treatment of BRPC. Therefore, in order to standardize and adjust neoadjuvant treatment in the future, new guidelines have to be determined on the basis of upcoming prospective randomized studies.

Reduced and Normalized Carbohydrate Antigen 19-9 Concentrations after Neoadjuvant Chemotherapy Have Comparable Prognostic Performance in Patients with Borderline Resectable and Locally Advanced Pancreatic Cancer

“…Surgical treatment is the mainstay for curative treatment. However, only 15-20% of diagnosed patients have resectable disease, and only 30% have borderline resectable disease [1]. Radical surgery, including vascular reconstruction, has been reported as technically feasible, expanding surgical indications for PDAC [2].…”

“…Although the optimal NACT regimen has not yet been determined, a recent meta-analysis found that FOLFIRINOX-based NACT yielded better oncologic outcomes than gemcitabine-based NACT, despite the former having greater toxicity [1,7]. The resection rate after NACT was 65.3%, with 57.4% of the patients who underwent surgery achieving R0 resection [7].…”

Exploring the Complementarity of Pancreatic Ductal Adenocarcinoma Preclinical Models

“…Clinical manifestations of PDAC often present with metastatic disease and consequently patient outlook is extremely poor [5]. Moreover, 15-20% of pancreatic cancer patients are deemed resectable whilst approximately 30% are borderline resectable [6]. Thus chemotherapy is the only available option to improve clinical outcomes for patients who have an unresectable disease [7].…”

Robotic Whipple for pancreatic ductal and ampullary adenocarcinoma: 10 years experience of a US single‐center

“…Pancreatic adenocarcinoma (PAC) is one of the most aggressive malignancies and causes in the United States approximately 53 000 deaths every year 1 . Despite considerable advances in surgical techniques and medical treatment, 2 the overall 5‐year patient survival of successful resections is an abysmal 20% 3 . Additionally, only 15% to 20% of patients present with surgically resectable disease.…”