Neoadjuvant Therapy for Borderline Resectable Pancreatic Head Cancer

Abstract

Borderline resectable pancreatic head cancer represents a relatively new classification for patients with intermediate tumors between those that are well-localized with no radiographic evidence of significant mesenteric vascular involvement and those considered to have locally advanced and technically unresectable disease based on the inability to safely perform a vascular resection and reconstruction of the vital blood vessels. These tumors can be removed but are likely to require major vascular resection and reconstruction and the incidence of margin-positive resections is high. Clinical trials with adjuvant therapy after resection of pancreatic head cancers have demonstrated survival benefits for multi-modality therapy compared to surgery alone. Because of the high likelihood of a margin-positive resection, neoadjuvant strategies employing chemotherapy with and without radiation therapy have been used in single institution or limited clinical trials. Biologic considerations and clinical justifications exist to support this approach, but to date, there are no sufficiently powered randomized clinical trials that demonstrate significant improvements in local control rates, disease-free survival and overall survival rates compared to a surgery-first approach. Clinical trials employing novel chemotherapy combinations and modified radiation approaches are underway and may provide more definitive evidence in the near future.