How A Patient with Resectable or Borderline Resectable Pancreatic Cancer should Be Treated-A Comprehensive Review

Abstract

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease with high morbidity and mortality in which long-term survival rates remain disastrous. Surgical resection is the only potentially curable treatment for early pancreatic cancer; however, the right patient qualification is crucial for optimizing treatment outcomes. With the rapid development of radiographic and surgical techniques, resectability decisions are made by a multidisciplinary team. Upfront surgery (Up-S) can improve the survival of patients with potentially resectable disease with the support of adjuvant therapy (AT). However, early recurrences are quite common due to the often-undetectable micrometastases occurring before surgery. Adopted by international consensus in 2017, the standardization of the definitions of resectable PDAC (R-PDAC) and borderline resectable PDAC (BR-PDAC) disease was necessary to enable accurate interpretation of study results and define which patients could benefit from neoadjuvant therapy (NAT). NAT is expected to improve the resection rate with a negative margin to provide significant local control and eliminate micrometastases to prolong survival. Providing information about optimal sequential multimodal NAT seems to be key for future studies. This article presents a multidisciplinary concept for the therapeutic management of patients with R-PDAC and BR-PDAC based on current knowledge and our own experience.

Keywords: adjuvant; borderline resectable; chemotherapy; neoadjuvant; pancreatic cancer; radiotherapy; resectable; resection.

Figure 1

CT image of resectable pancreatic ductal adenocarcinoma (R-PDAC). (A,B) A coronal and (C,D) and axial base during the pancreatic phase of CT demonstrating hypovascular mass in pancreatic body without PV, SMA and SV involvement. SMV—superior mesenteric vein, PV—portal vein, SMA—superior mesenteric artery, CA—celiac artery, CHA—common hepatic artery, PHA—proper hepatic artery, SV—splenic vein.

Figure 2

Proposed treatment algorithm. Diagnosis and stage of PDAC confirmed by CT/MRI. CA 19-9 more than 500 IU/mL, suspicious regional lymph metastasis in CT scan, PS = 2—consideration for NAT. Abbreviations: PDAC—pancreatic ductal adenocarcinoma, CA 19-9—carbohydrate antigen 19-9, PS—performance status, BR-PDAC—borderline resectable PDAC, R-PDAC—resectable PDAC, NAT-CTH—neoadjuvant chemotherapy, Up-S—upfront surgery, CT—computed tomography, CRTH—chemoradiotherapy, AT CTH—adjuvant chemotherapy.