Contemporary Multidisciplinary Treatment of Borderline-Resectable and Locally Advanced Pancreatic Adenocarcinoma

Pancreatic ductal adenocarcinoma remains a highly lethal malignancy, with borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) representing biologically and anatomically complex subsets requiring coordinated multidisciplinary care. Contemporary management integrates effective systemic therapy, selective use of radiation, dynamic assessment of treatment response, and carefully tailored surgical strategies to optimize margin-negative resection and long-term outcomes. Modern induction regimens serve as the foundation for disease control and biologic selection in both BRPC and LAPC, with emerging evidence supporting treatment adaptation on the basis of radiographic and biomarker response. Radiation therapy has evolved from conventional chemoradiation to ablative-dose techniques, which may offer durable local control in highly selected responders, although survival benefits remain to be defined in ongoing randomized trials. Surgical resection after induction chemotherapy remains the only potentially curative option. Venous resection is well established and safe in experienced centers, whereas arterial resection is reserved for exceptional responders with reconstructable disease because of increased perioperative risk and conflicting evidence of oncologic benefit. Complementary biomarkers and emerging molecular signatures are increasingly informing treatment sequencing and selection. The integration of advanced systemic therapy, tailored integration of radiation therapy, careful surgical selection, molecular profiling, and adaptive clinical trial designs reflects an accelerating shift toward personalized multimodality management aimed at improving survival in BRPC and LAPC.