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Review
. 2015 Aug;6(4):418-29.
doi: 10.3978/j.issn.2078-6891.2015.053.

Neoadjuvant therapy for localized pancreatic cancer: guiding principles

Amir Fathi  1 , Kathleen K Christians  1 , Ben George  1 , Paul S Ritch  1 , Beth A Erickson  1 , Parag Tolat  1 , Fabian M Johnston  1 , Douglas B Evans  1 , Susan Tsai  1
Affiliations
Review

Neoadjuvant therapy for localized pancreatic cancer: guiding principles

Amir Fathi et al. J Gastrointest Oncol. 2015 Aug.

Abstract

The management of localized pancreatic cancer (PC) remains controversial. Historically, patients with localized disease have been treated with surgery followed by adjuvant therapy (surgery-first approach) under the assumption that surgical resection is necessary, even if not sufficient for cure. However, a surgery-first approach is associated with a median overall survival of only 22-24 months, suggesting that a large proportion of patients with localized PC have clinically occult metastatic disease. As a result, adjuvant therapy has been recommended for all patients with localized PC, but in actuality, it is often not received due to the high rates of perioperative complications associated with pancreatic resections. Recognizing that surgery may be necessary but usually not sufficient for cure, there has been growing interest in neoadjuvant treatment sequencing, which benefits patients with both localized and metastatic PC by ensuring the delivery of oncologic therapies which are commensurate with the stage of disease. For patients who have clinically occult metastatic disease, neoadjuvant therapy allows for the early delivery of systemic therapy and avoids the morbidity and mortality of a surgical resection which would provide no oncologic benefit. For patients with truly localized disease, neoadjuvant therapy ensures the delivery of all components of the multimodality treatment. This review details the rationale for a neoadjuvant approach to localized PC and provides specific recommendations for both pretreatment staging and treatment sequencing for patients with resectable and borderline resectable (BLR) disease.

Keywords: Pancreatic cancer (PC); neoadjuvant therapy.

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Figures

Figure 1
Figure 1
Locally advanced PC. SMA is labelled with * and arrows define the hypodense tumor which encases (>180 degrees) of the SMA. PC, pancreatic cancer.
Figure 2
Figure 2
BLR PC. SMV is labelled with # and SMA is labelled with *. Note the hypodense tumor which abuts both the SMV and SMA. BLR, borderline resectable; PC, pancreatic cancer.
Figure 3
Figure 3
Resectable PC. SMV is labelled with # and SMA is labelled with *. A hypodense tumor is present in the pancreatic head with preservation of the fat plane between the pancreas and the SMV. No tumor abutment of the SMA. PC, pancreatic cancer.
Figure 4
Figure 4
Algorithm for determining clinical disease stage in PC. PC, pancreatic cancer.
Figure 5
Figure 5
Treatment sequencing in (A) resectable and (B) BLR PC. CA19-9, carbohydrate antigen 19-9; BLR, borderline resectable; PC, pancreatic cancer.
See this image and copyright information in PMC

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