From the Guidelines
The conversion rate to resectable disease in borderline resectable pancreatic cancer is approximately 24% with neoadjuvant therapy, as reported in the most recent guidelines 1.
Background
Borderline resectable pancreatic cancer (BR-PDAC) is a type of pancreatic cancer that is considered potentially resectable, but with a higher risk of positive margins due to the involvement of neighboring vascular structures. The management of BR-PDAC has evolved in recent years, with a focus on neoadjuvant therapy to downstage the tumor and improve the chances of successful resection.
Neoadjuvant Therapy
Neoadjuvant therapy, typically consisting of chemotherapy with regimens such as FOLFIRINOX or gemcitabine plus nab-paclitaxel, has been shown to improve the conversion rate to resectable disease in BR-PDAC patients. According to the REDISCOVER guidelines 1, neoadjuvant chemotherapy permitted resection in around 24% of patients with BR-PDAC. This approach allows for a selection based on response to treatment, and oncology guidelines currently suggest considering surgical resection when such control or regression is observed.
Factors Influencing Conversion to Resectability
The conversion to resectability depends on several factors, including the initial extent of vascular involvement, response to neoadjuvant therapy, and the specific criteria used to define borderline resectability. Successful conversion allows for surgical resection, which offers the only potential for cure in pancreatic cancer. However, even with conversion to resectable disease, the overall prognosis remains guarded, with five-year survival rates of approximately 20-25% for those who undergo successful resection after neoadjuvant therapy.
Key Considerations
- Neoadjuvant therapy should be administered at or coordinated through a high-volume center, as recommended by the NCCN guidelines 1.
- The best regimens to use in the borderline neoadjuvant setting are unknown, and clinical trials are ongoing to assess outcomes for specific regimens.
- The putative benefits of neoadjuvant therapy include increasing the likelihood of a margin-free resection, selecting for surgery patients with more stable disease, and treating micrometastases at an earlier stage.
From the Research
Conversion Rate to Resectable Disease
- The conversion rate to resectable disease in borderline resectable pancreatic cancer is approximately 63.6% of patients who undergo neoadjuvant therapy, as reported in a study published in 2019 2.
- Factors associated with an increased chance of surgical resection include lower ECOG performance status and neck location of the tumor 2.
- Neoadjuvant chemotherapy is administered to the majority of patients (94.0%) with borderline resectable pancreatic cancer, and 51.7% of patients receive radiation therapy in the neoadjuvant setting 2.
- The median overall survival from the date of diagnosis for resected borderline resectable pancreatic cancer patients is 28.8 months, compared to 14.5 months for those who do not undergo resection 2.
Treatment Outcomes
- Borderline resectable pancreatic cancer accounts for about 10-15% of newly diagnosed pancreatic cancer, and its management requires a skilled multidisciplinary team 3.
- The main definition of borderline resectable pancreatic cancer refers to resectability, but also a high risk of positive surgical margins and recurrence 3.
- Treatment of borderline resectable pancreatic adenocarcinoma typically involves neoadjuvant chemotherapy and/or chemoradiation before resection, with the goal of achieving a margin-negative resection 4.
- The use of FOLFIRINOX and gemcitabine plus nanoparticle albumin-bound (nab)-paclitaxel as first-line chemotherapy regimens for localized pancreatic ductal adenocarcinoma has been evaluated, with FOLFIRINOX associated with higher rates of RECIST partial response and subsequent pancreatectomy 5.