A Systematic Review of Neoadjuvant Therapy Compared to the “Resection First” Approach for Patients with Borderline Resectable Pancreatic Adenocarcinoma

Abstract

Background: Survival for patients with pancreatic adenocarcinoma continues to be poor. Patients with pancreatic adenocarcinoma that is deemed borderline resectable have imaging that shows disease involvement of the portal vein and/or superior mesenteric vein that is amenable to reconstruction or abutment (≤180 degrees) of the superior mesenteric artery. The best initial treatment for patients with borderline resectable pancreatic adenocarcinoma has yet to be determined. Proponents of neoadjuvant therapy purport its utility for patients with borderline resectable pancreatic adenocarcinoma with the intention of increasing the likelihood of a microscopically negative (R0) margin, but the consequences of this approach are not established. This study was undertaken to systematically review the outcomes for patients with borderline resectable pancreatic adenocarcinoma to compare neoadjuvant therapy to a "resection first" approach. Methods: A MEDLINE/PubMed search was undertaken to find all studies regarding patients who underwent neoadjuvant therapy for patients with borderline resectable pancreatic adenocarcinoma. Results: A total of 112 studies were found regarding borderline resectable pancreatic cancer. Fourteen studies contained cohorts of patients with borderline resectable pancreatic adenocarcinoma who received neoadjuvant therapy (n = 471 patients) or a resection-first approach (n = 76 patients). Resection after neoadjuvant therapy was undertaken for 233 (49%) patients. Neoadjuvant therapy followed by an R0 resection occurred for 42% of patients. For patients who underwent resection first, 71% (54/76) had an R0 margin. Conclusion: Patients with borderline resectable pancreatic adenocarcinoma were more often found to undergo neoadjuvant therapy than a "resection first" approach in the available literature. Although neoadjuvant therapy portends a high rate of R0 resections, less than half of the patients who undergo neoadjuvant therapy for borderline resectable pancreatic adenocarcinoma undergo resection. Patients who undergo "resection first" for borderline resectable pancreatic adenocarcinoma have an increased chance for a resection and an R0 margin compared to patients who undergo neoadjuvant therapy for borderline pancreatic adenocarcinoma.

Cost Analysis of Pancreaticoduodenectomy at a High-Volume Robotic Hepatopancreaticobiliary Surgery Program

“…6,7,9 Margins achieved were better (ie more R0 resections) with the robotic approach, but while this seems consistent with what others have reported, 10 there is room for improvement; neoadjuvant therapy was not uniformly applied, reflecting our bias. 11 We have previously reported that our patients had fewer complications than reported within NSQIP, and this group of patients looked like those previously reported. 3 Complications were relatively uncommon, occurring in fewer than 1 of 5 patients, and were generally not serious, with only 1 of 3 patients with a complication having a complication of grade 3 or greater; this means that less than 1 in 15 patients had a complication of grade 3 or greater.…”