Management of resectable and borderline resectable disease: Medical oncology

Localized pancreatic cancer (PDAC) is now recognized as a clinically heterogeneous entity. An estimated 20% of PDAC patients present with surgically resectable disease, while another 30% have locally advanced, unresectable cancers. Modern, multi-detector imaging using pancreatic protocols has illustrated a third category-borderline resectable PDAC. Management of these cancers is complex and multi-disciplinary. Neoadjuvant therapy prior to surgical resection is now considered "standard" for the management of borderline resectable PDAC. Increasingly, a similar strategy is also being utilized for resectable disease. Multiagent regimens like FOLFIRINOX have increased overall survival following pancreatectomy as compared with single-agent gemcitabine and these regimens are now being investigated in the neoadjuvant setting. Radiotherapy may impact local progression, which is an important cause of morbidity and mortality. However, the role of neoadjuvant chemoradiation vs. chemotherapy alone has not been prospectively investigated. Molecular profiling using the next generation sequencing technologies when applied to circulating tumor DNA may have utility for subsequent targeted therapies and early detection of recurrence. Metastatic PDAC is not surgically resectable. In rare instances however, metachronous, solitary lung nodules may be considered for preoperative therapy.