Although the concept of using neoadjuvant therapy is to downsize the tumor and enable margin-negative resection, a number of patients with BRPC, such as patients with small-volume disease with a short segment of PV-SMV involvement of less than 180 degrees, can also receive R0 resection without downsizing. If subjected to neoadjuvant therapy, these patients are at a risk of disease progression, which is reported to be in the range of 10% to 40%.4,5 Clearly, there is still a role for upfront surgery in these patients. Our own high-volume experience at the Tata Memorial Hospital, in Mumbai, India, seems to suggest that all patients need not receive neoadjuvant treatment, and well-selected patients can receive margin-negative upfront surgical resections.6
However, the rationale for neoadjuvant therapy is not only to minimize the risk of a positive resection margin but also to treat occult systemic disease. Unfortunately, there have been no randomized clinical trials addressing the impact of neoadjuvant therapy on overall survival as compared with upfront surgery. Lower-level evidence does suggest improvement in R0 resections, but that has not translated into improved overall or disease-free survival. Future clinical trials should be planned to assess the actual long-term benefits with neoadjuvant approaches.
Read “Borderline Resectable Pancreatic Cancer: The Search for the Best-Suited Treatment Strategy” published in ASCO Daily News, on Dec 19, 2018.