How to treat borderline resectable pancreatic cancer: current challenges and future directions

Borderline resectable pancreatic cancer (BRPC) is an advanced tumor in contact with the surrounding major vessels, making R0 resection difficult to achieve. Neoadjuvant treatment is expected to provide substantial local control and prolong survival. However, there is no standard treatment. I therefore conducted a strategic literature search from January 2013 to September 2017 and identified 37 clinical studies of pancreatic cancer, including BRPC, to evaluate treatment interventions. Twenty (54%) studies were prospective. Neoadjuvant regimens were as follows: chemotherapy (CT) followed by chemoradiotherapy (CRT) or radiotherapy (RT) (n = 16, 43%), CT alone (n = 11, 30%), CRT alone (n = 9, 24%) and RT alone (n = 1, 3%). Radiotherapy was employed in 70% of the studies. Phase II studies were most frequent (55%), and we were unable to identify a Phase III study. The National Comprehensive Cancer Network's classifications were most frequently used as criteria for BRPC, although resectability status is not standardized. Radiological central review was used in three of eight multi-institutional studies. Assessing on-going or planned clinical trials for BRPC, administration of oxaliplatin, irinotecan, fluorouracil and leucovorin therapy or albumin-bound paclitaxel plus gemcitabine therapy, and randomized trials that evaluate the significance of CRT or RT combined with CT were identified as important topics for further consideration. Although standardization of classifications and improvement of infrastructure are required, a standard treatment of BRPC will likely be developed, which will improve prognosis in the near future because several important randomized trials are running.