Surgical Perspectives on Neoadjuvant Therapy in Borderline Resectable and Locally Advanced Pancreatic Cancer

Area of Science:

• Surgical Oncology
• Gastroenterology
• Medical Oncology

Background:

• Neoadjuvant therapy (NAT) is crucial for managing borderline resectable (BRPC) and locally advanced pancreatic ductal adenocarcinoma (PDAC).
• Current management emphasizes pretreatment classification, post-NAT selection, intraoperative vascular strategies, and postoperative care.

Purpose of the Study:

• To review contemporary evidence and guidelines for NAT in BRPC and LAPC from a surgical viewpoint.
• To highlight key considerations in patient selection, restaging, and surgical approaches post-NAT.

Main Methods:

• Structured narrative review of randomized trials, prospective studies, observational cohorts, and international guidelines.
• Literature search updated through July 31, 2025.

Main Results:

• NAT is the preferred initial strategy for BRPC and standard for LAPC, with resection reserved for responders.
• Restaging combines contrast-enhanced CT and CA19-9 kinetics, supplemented by advanced imaging and biomarkers.
• Vascular resection is margin-driven; venous resection is established in expert centers, arterial resection is selective, and periarterial divestment is an alternative.

Conclusions:

• NAT has reshaped pancreatic cancer treatment into a biology-guided, time-sequenced surgical pathway.
• Optimizing outcomes requires standardized reassessment, meticulous patient selection, and centralization of complex vascular procedures.