Borderline Resectable Pancreatic Cancer: On the Edge of Survival

Gregory M. Springett, MD, PhD; Sarah E. Hoffe, MD

Disclosures

Cancer Control. 2008;15(4):295-307. 

In This Article

Abstract and Introduction

Abstract

Background: Patients with borderline resectable pancreatic cancer are at high risk of having positive surgical margins due to involvement of the tumor with adjacent vasculature. This article reviews the management of this subset of pancreatic cancer patients.
Methods: The authors review the current definitions of borderline resectable pancreatic cancer and how it is diagnosed and staged. The history, current approaches, and future directions in neoadjuvant therapy for borderline resectable pancreatic cancer are also reviewed with emphasis on various chemotherapy regimens that have been used. The application of intensity-modulated radiation therapy and image-guided radiation therapy that accounts for respiratory motion to targeting the gross tumor volume in the pancreas are discussed, and the promise of integrating targeted therapies in neoadjuvant treatment programs is highlighted.
Results: The use of neoadjuvant treatment programs that employ gemcitabine-based chemotherapy regimens followed by chemoradiation increases the likelihood of subsequent margin-negative resection in borderline resectable pancreatic cancer.
Conclusions: There has been progress in the imaging, staging, surgical technique, and the use of chemotherapy and chemoradiotherapy in the management of borderline resectable pancreatic cancer. Patients can benefit from multidisciplinary management at high-volume pancreatic cancer treatment centers.

Introduction

The 5-year survival rate for patients with histologically confirmed metastatic ductal adenocarcinoma of the pancreas approaches 0%, with a median overall survival of 5 to 6 months.[1,2,3] Long-term survival after a diagnosis of pancreatic cancer is attained only in patients who are diagnosed prior to the development of distant metastasis and are able to undergo complete surgical resection with negative margins. This subset constitutes about 15% to 20% of all newly diagnosed pancreatic cancer patients.[4] Nevertheless, only about 20% of this subset (3% to 4% of all patients) will survive beyond 5 years. The median overall survival of patients who undergo complete resection with negative margins ranges between 12 and 26 months.[5] Therefore, until more effective systemic therapy is discovered, complete surgical resection is the superior treatment modality for patients with resectable disease. Approximately one-third of patients presenting with locally advanced pancreatic cancer will be marginally or "borderline" resectable. The application of existing multimodality therapies, despite their limited efficacy, can have the greatest impact on the borderline pancreatic cancer patient by downstaging them to resectability. In principle, a modest tumor response to neoadjuvant therapy may translate into a potential doubling of survival and preservation of the opportunity for cure by facilitating successful resection with negative margins.

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