A neoadjuvant strategy for the management of nonmetastatic pancreatic cancer

Treatment of pancreatic cancer has become increasingly multimodal, with patients undergoing chemotherapy, radiation, and surgical extirpation in hope of long-term cures. There is ongoing debate over the timing, sequence, and necessity of these treatments as they pertain to the spectrum of local regional disease. This review examines the literature of a neoadjuvant treatment strategy as stratified by initial tumor evaluation (potentially resectable, borderline resectable, and locally advanced disease), highlighting preoperative emergence of latent metastatic disease, attempted resection rates, margin negative (R0) resection rates, and pathologic response to treatment. Guidelines currently support a neoadjuvant strategy in patients with borderline resectable disease. Although there is currently no high-level evidence to recommend neoadjuvant therapy for all patients, there is suggestive evidence that such a strategy may be beneficial and random-assignment prospective trials are ongoing.