Neoadjuvant therapy in pancreatic cancer: what is the true oncological benefit?
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REVIEW ARTICLE
Neoadjuvant therapy in pancreatic cancer: what is the true oncological benefit? Lei Ren 1,2 & Carmen Mota Reyes 1 & Helmut Friess 1,3,4 & Ihsan Ekin Demir 1,3,4,5 Received: 19 July 2020 / Accepted: 22 July 2020 # The Author(s) 2020
Abstract Background Neoadjuvant therapies (neoTx) have revolutionized the treatment of borderline resectable (BR) and locally advanced (LA) pancreatic cancer (PCa) by significantly increasing the rate of R0 resections, which remains the only curative strategy for these patients. However, there is still room for improvement of neoTx in PCa. Purpose Here, we aimed to critically analyze the benefits of neoTx in LA and BR PCa and its potential use on patients with resectable PCa. We also explored the feasibility of arterial resection (AR) to increase surgical radicality and the incorporation of immunotherapy to optimize neoadjuvant approaches in PCa. Conclusion For early stage, i.e., resectable, PCa, there is not enough scientific evidence for routinely recommending neoTx. For LA and BR PCa, optimization of neoadjuvant therapy necessitates more sophisticated complex surgical resections, machine learning and radiomic approaches, integration of immunotherapy due to the high antigen load, standardized histopathological assessment, and improved multidisciplinary communication. Keywords Pancreatic cancer . Neoadjuvant therapy . Arterial resection . Immunotherapy
Introduction The introduction of neoTx has led to a remarkable increase in the rate of surgical resections in PCa patients with LA or BR tumors, which were initially deemed inoperable at the time of diagnosis. However, two-thirds of these patients will develop local recurrences shortly after the operation [1]. In order to Lei Ren and Carmen Mota Reyes contributed equally to this work. * Ihsan Ekin Demir [email protected] 1
Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, D-81675 Munich, Germany
2
Department of General Surgery (Gastrointestinal Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
3
German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
4
CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
5
Department of General Surgery, HPB Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
avoid disease relapse, surgeons have struggle to find ways to maximize R0 resections that still remain the only curative alternative for long-term survival in PCa. Although the first attempts of arterial resections (AR) in advanced tumors did not show the expected success, improved perioperative management and the integration of neoTx into multimodal therapy approaches have resulted in significantly reduced perioperative mortality and have proven the safety and feasibility of these radical approaches. Although neoTx is the standard of care for BR and LA tumors, its application on upfront resectable patients in order to downstage tumors and to increase sur
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