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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Borderline resectable pancreatic cancer touches the big blood vessels behind the pancreas, so an operation straight away would probably leave cancer behind. Chemotherapy first, usually FOLFIRINOX for several months and sometimes radiotherapy, shrinks the edge of the tumour, and patients whose disease has not spread go on to surgery with a better chance of a clean removal.
Borderline resectable disease is defined anatomically: tumour contact with the superior mesenteric or portal vein that is reconstructable, abutment of the superior mesenteric artery of 180 degrees or less, or limited contact with the hepatic artery. The MD Anderson, NCCN and international consensus definitions differ in detail and some add biological criteria, such as a very high CA 19-9 or suspicious regional nodes, and conditional criteria such as poor performance status. The point of the category is that upfront surgery leaves a positive margin in a large share of patients and that neoadjuvant treatment selects those who will benefit from a difficult operation.
Neoadjuvant therapy is standard. PREOPANC-1 (2020, long-term follow-up 2022) randomised resectable and borderline patients to gemcitabine-based chemoradiation before surgery or upfront surgery and found more clear-margin resections and better long-term survival, with the benefit concentrated in the borderline group. PREOPANC-2 then compared neoadjuvant FOLFIRINOX with gemcitabine chemoradiation and found no difference, and ESPAC-5 found that neoadjuvant chemotherapy beat immediate surgery for borderline disease. Modified FOLFIRINOX for two to four months is the usual regimen, with gemcitabine plus nab-paclitaxel for less fit patients. The role of radiotherapy after chemotherapy is disputed: ALLIANCE A021501 (2022) stopped its stereotactic radiotherapy arm early because outcomes were worse than with chemotherapy alone, while other groups use conventional or ablative chemoradiation to secure the arterial margin.
| Setting | Approach | Guideline |
|---|---|---|
| Neoadjuvant chemotherapy | Modified FOLFIRINOX for two to four months in fit patients, gemcitabine plus nab-paclitaxel otherwise; restage with CT and CA 19-9 before deciding on surgery (PREOPANC, ESPAC-5). | not mapped |
| Radiotherapy after chemotherapy | Optional; conventional chemoradiation or stereotactic radiotherapy to secure an arterial margin in selected patients, with ALLIANCE A021501 as the caution against routine use. | not mapped |
| Surgery | Pancreatoduodenectomy or distal pancreatectomy with venous resection and reconstruction where needed, arterial resection only in specialist centres; proceed on stable or improved disease with falling CA 19-9. | not mapped |
| After surgery | Complete six months of chemotherapy in total, usually with the regimen the tumour responded to. | not mapped |
| Progression during neoadjuvant therapy | Manage as locally advanced or metastatic disease; switch chemotherapy backbone, RAS inhibitor trials, biliary stenting for jaundice. | not mapped |