Essential updates 2019/2020: Multimodal treatment of localized pancreatic adenocarcinoma: Current topics and updates in survival outcomes and prognostic factors

Abstract

Overall survival of patients with localized pancreatic ductal adenocarcinoma (PDAC) is extremely poor. Therefore, the establishment of multimodal treatment strategies is indispensable for PDAC patients because surgical treatment alone could not contribute to the improvement of survival. In this review article, we focus on the current topics and advancement of the treatments for localized PDAC including resectable, borderline resectable, and locally advanced PDAC in accordance with the articles mainly published from 2019 to 2020. Reviewing the articles, the recent progress of multimodal treatments notably improves the prognosis of patients with localized PDAC. For resectable PDAC, neoadjuvant chemo or chemoradiation therapy, rather than upfront surgery, plays a key role, especially in patients with a large tumor, poor performance status, high tumor marker levels, peripancreatic lymph nodes metastasis, or neural invasion suspected on preoperative imaging. For borderline resectable PDAC, neoadjuvant treatments followed by surgery is a desirable approach, and maintenance of immunonutritional status during the treatments are also important. For locally advanced disease, conversion surgery has a central role in improving a survival outcome; however, its indication should be standardized.

Current status and perspectives of the future of pancreatic surgery: Establishment of evidence by integration of “art” and “science”

“… 42 , 43 Criteria for imaging and non‐anatomical criteria such as tumor markers, patient condition, and genetic profiling are also being developed. 44 In particular, establishing criteria for biological markers and morphological and functional imaging after neoadjuvant therapy is challenging. 45 Furthermore, the appropriate timing of surgery (upfront or after neoadjuvant therapy) and conversion surgery is fiercely debated.…”

“…Recently, the biological criteria proposed by the MD Anderson Cancer Center and the International Association of Pancreatology (IAP) have been validated 42, 43 . Criteria for imaging and non‐anatomical criteria such as tumor markers, patient condition, and genetic profiling are also being developed 44 . In particular, establishing criteria for biological markers and morphological and functional imaging after neoadjuvant therapy is challenging 45 .…”

Evaluating staging laparoscopy indications for pancreatic cancer based on resectability classification and treatment strategies for patients with positive peritoneal washing cytology

“…9,10 Previous reports also suggest that PDAC patients with occult distant metastases have a poor prognosis, and accurate staging by SL can reduce unnecessary noncurative resections. 2,11,12 Diagnostic and multidisciplinary treatment strategies for PDAC are constantly improving, 13 resulting in the introduction of new surgical techniques. 14 Systemic chemotherapies, such as FOLFIRINOX (fluorouracil, irinotecan, and oxaliplatin [FFX]) and gemcitabine along with nab-paclitaxel (GnP), are generally used for unresectable PDAC.…”

“…Diagnostic and multidisciplinary treatment strategies for PDAC are constantly improving, 13 resulting in the introduction of new surgical techniques 14 . Systemic chemotherapies, such as FOLFIRINOX (fluorouracil, irinotecan, and oxaliplatin [FFX]) and gemcitabine along with nab‐paclitaxel (GnP), are generally used for unresectable PDAC 15,16 .…”

Paradigm shift for defining the resectability of pancreatic cancer

“…Therefore, in addition to determining the treatment option at diagnosis, additional decision-making is required for subsequent treatment if the first treatment is NAT or non-surgical treatment. As can be seen from the initial treatment methods according to the resectability category, the indications for NAT are gradually expanding [ 9 ]. In addition, NAT has been used in RPC with a high risk of early systemic recurrence as predicted by various biological or anatomical markers [ 1 ].…”