Neoadjuvant Treatment of Pancreatic Cancer: When and How?
Marta Sandini, Thilo Hackert, Ulla Klaiber, Markus W. Büchler, John P. Neoptolemos
The European Study Group for Pancreatic Cancer (ESPAC)-1 trial was the first large randomized trial to show a significant survival benefit for the use of adjuvant chemotherapy with 5-fluorouracil (5FU) and folinic acid following pancreatic cancer resection, whilst also demonstrating that adjuvant chemoradiotherapy did not prolong survival. The ESPAC-3 trial in 2010 showed that adjuvant monotherapy with gemcitabine was not superior to 5FU and folinic acid with regard to survival, but was less toxic. Neoadjuvant chemotherapy is an emerging concept for resectable, borderline resectable, and locally advanced pancreatic ductal adenocarcinoma (PDAC). Guidelines are inconsistent in the recommendations for neoadjuvant therapy in resectable, borderline resectable, and locally advanced PDAC. The Heidelberg approach is to proceed to surgical exploration after neoadjuvant therapy, provided the patient has maintained a good performance status and no evidence of metastases on coaxial imaging.
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