[Evidence for Neoadjuvant Therapy in Resectable Pancreatic Cancer]

Pancreatic cancer could be the second leading cause of cancer death in 2030. Even though 5-year survival rates remain poor, substantial progress has been made in recent decades. The use of adjuvant chemotherapy after resection has prolonged survival and neoadjuvant concepts have been introduced to allow proportionately more resections in initially borderline resectable or locally advanced disease. Currently, there is an ongoing debate about the use of neoadjuvant therapy in both resectable and borderline resectable disease, whereas in locally advanced cancer, the use of neoadjuvant therapies is unquestionable. High-level evidence in this area remains scarce, despite numerous studies that have recently been published or are currently recruiting. A key problem is the definition of resectability which was - traditionally - based on anatomical criteria; however, it has become clear that this definition is not adequate as tumour biology as well as patient-related prognostic factors are not taken into consideration. A second unsolved problem is the difficulty to standardise neoadjuvant therapy as - in contrast to the adjuvant setting, where large randomised controlled trials have set clear standards - multiple protocols are used around the world. This does not allow us to give any clear recommendation on which therapy protocol should be chosen for a specific patient if neoadjuvant therapy is considered. Furthermore, success control under neoadjuvant treatment is not effectively defined - usually only CA 19-9 as the most common marker can aid in clinical decision making, as imaging often fails to show actual response. With regard to present guidelines, patients with resectable disease should not be treated with neoadjuvant therapy outside clinical studies, whereas for borderline resectable disease, recommendations vary between different countries and societies.This review summarises the present literature on the topic of neoadjuvant therapy in pancreatic cancer with a focus on resectable disease stage.