Borderline Resectable Pancreatic Cancer: The Importance of This Emerging Stage of Disease

Katz, Matthew H.; Pisters, Peter W.T.; Evans, Douglas B.; Sun, Charlotte C.; Lee, Jeffrey E.; Fleming, Jason B.; Vauthey, Jean‐Nicolas; Abdalla, Eddie K.; Crane, Christopher H.; Wolff, Robert A.; Varadhachary, Gauri R.; Hwang, Rosa F.

doi:10.1016/j.jamcollsurg.2007.12.020

Cited by 729 publications

(536 citation statements)

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“…However, surgery is not an option for patients who initially present with locally advanced (AJCC stage III) disease and who have a reported median survival period of less than 12 months (35). Therefore, in clinical practice, stage-specific treatment of pancreatic adenocarcinoma is based on whether a tumor is potentially resectable, locally advanced or metastatic, and, therefore, the fundamental question in the initial staging evaluation of pancreatic adenocarcinoma is the determination of resectability (15).…”

Section: Discussionmentioning

confidence: 99%

Preoperative evaluation of pancreatic cancer: Comparison of gadolinium‐enhanced dynamic MRI with MR cholangiopancreatography versus MDCT

Park

Lee

Choi

et al. 2009

Magnetic Resonance Imaging

134

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Purpose:To determine the accuracy of magnetic resonance imaging (MRI) including dynamic imaging using three-dimensional gradient-echo (3D-GRE) sequences and MR cholangiopancreatograpy (MRCP) compared with that of multidetector row CT (MDCT) with regard to resectability in pancreas cancer. Materials and Methods:From February 2004 to July 2008, 54 patients (32 men, 22 women: age range, 28 -83 years; mean age, 63.1 years old) with surgically proven pancreatic carcinoma, who had undergone preoperative gadolinium-enhanced 3D-GRE MRI with MRCP and triplephase MDCT, were included in this retrospective study. Two, clinically experienced attending radiologists independently reviewed the two image sets. These readers evaluated the tumor conspicuity, presence of vascular invasion, choledochal and duodenal invasion, lymph node metastases, distant metastasis, and tumor resectability. The results were compared with the surgical and histopathologic findings using receiver operating characteristic analysis (Az) and kappa statistics. Results:Curative resections were performed on 42 patients. Regarding the tumor conspicuity, MRI had a significantly higher Az value compared with MDCT according to both reviewers (P Ͻ 0.05). The accuracy of resectability was Az ϭ 0.753 and 0.768 on MRI and Az ϭ 0.829 and 0.762 on MDCT for each reviewer, and the difference in the accuracy of resectability was not significant between MRI and MDCT for either reviewer (P Ͼ 0.05). Two imaging sets showed a similar diagnostic performance in the evaluation of vascular involvement, lymph node metastasis, and distant metastasis.Conclusion: Dynamic 3D-GRE MRI with MRCP shows superior tumor conspicuity and similar diagnostic performance compared with MDCT in evaluating the resectability of pancreatic cancer.

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Section: Discussionmentioning

confidence: 99%

Preoperative evaluation of pancreatic cancer: Comparison of gadolinium‐enhanced dynamic MRI with MR cholangiopancreatography versus MDCT

Park

Lee

Choi

et al. 2009

Magnetic Resonance Imaging

134

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“…Our hypothesis was that more effective systemic therapy would increase the potential of patients to complete all intended therapy, including surgery, by effectively treating both the local tumor and radiographically occult micrometastases. Stated another way, disease progression at the time of restaging or surgery would be less common than historically reported in the MD Anderson experience in which less than 50% of patients with borderline resectable disease completed all therapy including successful pancreatectomy [2]. More effective induction therapy including FOLFIRINOX represents a potential solution to the problem of borderline resectable pancreas cancer as long as chemotherapy-related toxicity does not preclude completion of all planned treatment including surgery.…”

Section: Introductionmentioning

confidence: 98%

Neoadjuvant FOLFIRINOX for Borderline Resectable Pancreas Cancer: A New Treatment Paradigm?

et al. 2014

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Background. Borderline resectable pancreatic cancer is best treated by multimodality therapy. FOLFIRINOX (5-fluorouracil, oxaliplatin, irinotecan, and leucovorin) tripled the response rate and significantly increased median survival for patients with advanced pancreatic cancer and shows promise for neoadjuvant use.Toxicity concerns prompted a careful analysis of our initial FOLFIRINOX experience. Methods. All patients diagnosed with borderline resectable, biopsy-proven pancreatic adenocarcinoma treated with neoadjuvant FOLFIRINOX between July 2010 and December 2012 were reviewed. Primary outcome was surgical resectability. Secondary outcomes were treatment-related toxicities and survival. Results. FOLFIRINOX followed by gemcitabine-or capecitabinebased chemoradiation was initiated in 18 patients. The most common grade 3 or 4 toxicities during chemotherapy were gastrointestinal, including nausea/emesis (n 5 5), weight loss (n 5 3) and diarrhea (n 5 2), and hematologic (n 5 2; neutropenia); five patients (36%) required a total of six

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“…The trials reviewed here have considerable limitations including the lack of standard definitions of BRPC and LAPC stages [2, 24,64]. Therefore, future treatment paradigms and clinical trials must distinguish these two stages on a clear ground.…”

Section: Practical Approach To Treatmentmentioning

confidence: 99%

Contemporary Management of Borderline Resectable and Locally Advanced Unresectable Pancreatic Cancer

Shaib

Cardona

et al. 2016

The Oncologist

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Adenocarcinoma of the pancreas remains a highly lethal disease, with less than 5% survival at 5 years. Borderline resectable pancreatic cancer (BRPC) and locally advanced unresectable pancreatic cancer (LAPC) account for approximately 30% of newly diagnosed cases of PC. The objective of BRPC therapy is to downstage the tumor to allow resection; the objective of LAPC therapy is to control disease and improve survival. There is no consensus on the definitions of BRPC and LAPC, which leads to major limitations in designing clinical trials and evaluating their results. A multimodality approach is always needed to ensure proper utilization and timing of chemotherapy, radiation, and surgery in the management of this disease. Combination chemotherapy regimens (5-fluorouracil, leucovorin, irinotecan, oxaliplatin, and gemcitabine [FOLFIRINOX] and gemcitabine/nab-paclitaxel) have improved overall survival in metastatic disease. The role of combination chemotherapy regimens in BRPC and LAPC is an area of active investigation. There is no consensus on the dose, modality, and role of radiation therapy in the treatment of BRPC and LAPC. This article reviews the literature and highlights the areas of controversy regarding management of BRPC and LAPC. The Oncologist 2016;21:178-187 Implications for Practice: Pancreatic cancer is one of the worst cancers with regard to survival, even at early stages of the disease. This review evaluates all the evidence for the stages in which the cancer is not primarily resectable with surgery, known as borderline resectable or locally advanced unresectable. Recently, advancements in radiation techniques and use of better combination chemotherapies have improved survival and tolerance. There is no consensus on description of stages or treatment sequences (chemotherapy, chemoradiation, radiation), nor on the best chemotherapy regimen. The evidence behind the treatment paradigm for these stages of pancreatic cancer is summarized.

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Borderline Resectable Pancreatic Cancer: The Importance of This Emerging Stage of Disease

Cited by 729 publications

References 10 publications

Preoperative evaluation of pancreatic cancer: Comparison of gadolinium‐enhanced dynamic MRI with MR cholangiopancreatography versus MDCT

Preoperative evaluation of pancreatic cancer: Comparison of gadolinium‐enhanced dynamic MRI with MR cholangiopancreatography versus MDCT

Neoadjuvant FOLFIRINOX for Borderline Resectable Pancreas Cancer: A New Treatment Paradigm?

Contemporary Management of Borderline Resectable and Locally Advanced Unresectable Pancreatic Cancer

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