Abstract
Pancreatic cancer has a very poor prognosis, with the projection to be the second leading cancer-related death in 2020 [1]. Pancreatic cancer can be divided in three stages: resectable (15%), locally advanced (35%) and metastatic disease (50%) [2]. The diagnosis of resectable and locally advanced pancreatic cancer is determined by the tumor invasion of critical structures, in particular the portal vein, superior mesenteric vein, coeliac artery and superior mesenteric artery. This tumor invasion is usually assessed by contrast enhanced computed tomography (CT). There are several definitions for resectable and locally advanced disease, usually based on the tumor burden of the surrounding major vessels. This tumor burden can be defined as no invasion at all to the surrounding structures (resectable disease) and too much invasion in the surrounding structures to be deemed resectable (locally advanced disease). In between these two extremes there is a diagnostic gap where a tumor has some vessel involvement but is still resectable, this gap is called borderline resectable disease. The two most commonly used definitions for (borderline) resectable disease and locally advanced disease are that of National Comprehensive Cancer (NCCN) and the combined definition of Americas Hepato-Pancreato-Biliary Association (AHPBA), the Society of Surgical Oncology (SSO), and the Society for Surgery of the Alimentary Tract (SSAT) [3, 4]. Both the definitions of NCCN and AHPBA/SSO/SSAT for borderline resectable and locally advanced disease are summarized in Table 20.1. For decades, the primary treatment for borderline resectable pancreatic cancer was upfront surgery. However, neoadjuvant therapy is becoming more and more a valuable upfront therapy for borderline resectable disease. Although there is no clear level I evidence for this treatment [5]. The main purpose of neoadjuvant treatment are threefold: (1) improve probability of radical resection, (2) patient selection of patients with rapid disease progression that will undergo unnecessary surgery, (3) early treatment of occult metastasis and finally more patients receiving systemic treatment since a significant portion of patient do not come to adjuvant therapy after surgical resection due to morbidity [6]. In contrary, locally advanced pancreatic cancer is conventionally treated with induction chemotherapy and sometimes followed by local therapy such as (chemo)radiotherapy or local ablation. Surgery is not recommended as an upfront treatment in locally advanced unresectable pancreatic cancer and is only reserved for patients with disease response and after tumor downstaging with chemotherapy and or (chemo)radiotherapy [7]. In this chapter, an overview will be given of studies that examined the effect of neoadjuvant treatment on surgical outcomes in borderline resectable and locally advanced unresectable pancreatic cancer. Lastly, an illustrative case report will be presented of a patient with locally advanced unresectable pancreatic cancer.
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References
Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res. 2014;74(11):2913–21.
Stathis A, Moore MJ. Advanced pancreatic carcinoma: current treatment and future challenges. Nat Rev Clin Oncol. 2010;7(3):163–72.
Network. NCC. Pancreatic adenocarcinoma (version: 2.2015): NCCN. 2015. http://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf.
Callery MP, Chang KJ, Fishman EK, Talamonti MS, William Traverso L, Linehan DC. Pretreatment assessment of resectable and borderline resectable pancreatic cancer: expert consensus statement. Ann Surg Oncol. 2009;16(7):1727–33.
Heinemann V, Haas M, Boeck S. Neoadjuvant treatment of borderline resectable and non-resectable pancreatic cancer. Ann Oncol. 2013;24(10):2484–92.
David P, Ryan HM. Initial chemotherapy and radiation for nonmetastatic locally advanced unresectable and borderline resectable exocrine pancreatic cancer. In: Post TW, editor. UpToDate. Waltham: UpToDate.
Balaban EP, Mangu PB, Khorana AA, Shah MA, Mukherjee S, Crane CH, et al. Locally advanced, unresectable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2016;34(22):2654–68.
Chun YS, Milestone BN, Watson JC, Cohen SJ, Burtness B, Engstrom PF, et al. Defining venous involvement in borderline resectable pancreatic cancer. Ann Surg Oncol. 2010;17(11):2832–8.
Stokes JB, Nolan NJ, Stelow EB, Walters DM, Weiss GR, de Lange EE, et al. Preoperative capecitabine and concurrent radiation for borderline resectable pancreatic cancer. Ann Surg Oncol. 2011;18(3):619–27.
Kang CM, Chung YE, Park JY, Sung JS, Hwang HK, Choi HJ, et al. Potential contribution of preoperative neoadjuvant concurrent chemoradiation therapy on margin-negative resection in borderline resectable pancreatic cancer. J Gastrointest Surg. 2012;16(3):509–17.
Lee JL, Kim SC, Kim JH, Lee SS, Kim TW, Park DH, et al. Prospective efficacy and safety study of neoadjuvant gemcitabine with capecitabine combination chemotherapy for borderline-resectable or unresectable locally advanced pancreatic adenocarcinoma. Surgery. 2012;152(5):851–62.
Kim EJ, Ben-Josef E, Herman JM, Bekaii-Saab T, Dawson LA, Griffith KA, et al. A multi-institutional phase 2 study of neoadjuvant gemcitabine and oxaliplatin with radiation therapy in patients with pancreatic cancer. Cancer. 2013;119(15):2692–700.
Takahashi H, Ohigashi H, Gotoh K, Marubashi S, Yamada T, Murata M, et al. Preoperative gemcitabine-based chemoradiation therapy for resectable and borderline resectable pancreatic cancer. Ann Surg. 2013;258(6):1040–50.
Katz MH, Shi Q, Ahmad SA, Herman JM, Marsh Rde W, Collisson E, et al. Preoperative modified FOLFIRINOX treatment followed by capecitabine-based chemoradiation for borderline resectable pancreatic cancer: alliance for clinical trials in oncology trial A021101. JAMA Surg. 2016;151(8):e161137.
Asare EA, Evans DB, Erickson BA, Aburajab M, Tolat P, Tsai S. Neoadjuvant treatment sequencing adds value to the care of patients with operable pancreatic cancer. J Surg Oncol. 2016;114(3):291–5.
de Geus SW, Evans DB, Bliss LA, Eskander MF, Smith JK, Wolff RA, et al. Neoadjuvant therapy versus upfront surgical strategies in resectable pancreatic cancer: a Markov decision analysis. Eur J Surg Oncol. 2016;42(10):1552–60.
Mokdad AA, Minter RM, Zhu H, Augustine MM, Porembka MR, Wang SC, et al. Neoadjuvant therapy followed by resection versus upfront resection for resectable pancreatic cancer: a propensity score matched analysis. J Clin Oncol. 2017;35(5):515–23.
Versteijne E, van Eijck CH, Punt CJ, Suker M, Zwinderman AH, Dohmen MA, et al. Preoperative radiochemotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer (PREOPANC trial): study protocol for a multicentre randomized controlled trial. Trials. 2016;17(1):127.
Burris 3rd HA, Moore MJ, Andersen J, Green MR, Rothenberg ML, Modiano MR, et al. Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial. J Clin Oncol. 1997;15(6):2403–13.
Conroy T, Desseigne F, Ychou M, Bouche O, Guimbaud R, Becouarn Y, et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med. 2011;364(19):1817–25.
Suker M, Beumer BR, Sadot E, Marthey L, Faris JE, Mellon EA, et al. FOLFIRINOX for locally advanced pancreatic cancer: a systematic review and patient-level meta-analysis. Lancet Oncol. 2016;17(6):801–10.
Stein SM, James ES, Deng Y, Cong X, Kortmansky JS, Li J, et al. Final analysis of a phase II study of modified FOLFIRINOX in locally advanced and metastatic pancreatic cancer. Br J Cancer. 2016;114(7):737–43.
Von Hoff DD, Ervin T, Arena FP, Chiorean EG, Infante J, Moore M, et al. Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med. 2013;369(18):1691–703.
Shubert CR, Bergquist JR, Groeschl RT, Habermann EB, Wilson PM, Truty MJ, et al. Overall survival is increased among stage III pancreatic adenocarcinoma patients receiving neoadjuvant chemotherapy compared to surgery first and adjuvant chemotherapy: an intention to treat analysis of the National Cancer Database. Surgery. 2016;160(4):1080–96.
Evans DB, George B, Tsai S. Non-metastatic pancreatic cancer: resectable, borderline resectable, and locally advanced-definitions of increasing importance for the optimal delivery of multimodality therapy. Ann Surg Oncol. 2015;22(11):3409–13.
Rombouts SJ, Walma MS, Vogel JA, van Rijssen LB, Wilmink JW, Mohammad NH, et al. Systematic review of resection rates and clinical outcomes after FOLFIRINOX-based treatment in patients with locally advanced pancreatic cancer. Ann Surg Oncol. 2016;23(13):4352–60.
Cooper AB, Parmar AD, Riall TS, Hall BL, Katz MH, Aloia TA, et al. Does the use of neoadjuvant therapy for pancreatic adenocarcinoma increase postoperative morbidity and mortality rates? J Gastrointest Surg. 2015;19(1):80–6. discussion 6–7.
Addeo P, Rosso E, Fuchshuber P, Oussoultzoglou E, De Blasi V, Simone G, et al. Resection of borderline resectable and locally advanced pancreatic adenocarcinomas after neoadjuvant chemotherapy. Oncology. 2015;89(1):37–46.
Mellon EA, Strom TJ, Hoffe SE, Frakes JM, Springett GM, Hodul PJ, et al. Favorable perioperative outcomes after resection of borderline resectable pancreatic cancer treated with neoadjuvant stereotactic radiation and chemotherapy compared with upfront pancreatectomy for resectable cancer. J Gastrointest Oncol. 2016;7(4):547–55.
Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, et al. Potentially curable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2016;34(21):2541–56.
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Suker, M., van Eijck, C.H.J. (2017). Pancreatic Resection After Neoadjuvant Treatment. In: Cuesta, M. (eds) Minimally Invasive Surgery for Upper Abdominal Cancer. Springer, Cham. https://doi.org/10.1007/978-3-319-54301-7_20
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DOI: https://doi.org/10.1007/978-3-319-54301-7_20
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