Impact of neoadjuvant therapy on the surgical management of pancreatic cancer: a literature review

Survival after surgery for pancreatic cancer remains poor despite the use of multimodality treatment. Neoadjuvant strategies for patients with resectable, borderline resectable and locally-advanced disease are gaining acceptance and may improve outcomes. In this review we will summarize some of the studies supporting the use of neoadjuvant treatment and focus on the perioperative/operational aspects of executing a neoadjuvant treatment program. Currently, while neoadjuvant treatment is supported for borderline resectable and locally advanced patients, the evidence is equivocal on its use in the resectable setting. There appears also to be relatively little guidance from studies so far in assessing resectability after neoadjuvant treatment. Other issues that are not fully resolved include the timing of surgery, the use of vascular reconstruction, and assessing response to neoadjuvant treatment. Neoadjuvant treatment strategies appear to be feasible and relatively safe in terms of surgical morbidity and mortality. Response to treatment appears to be prognostic, but we lack reliable predictors of response to treatment prior to initiation. Our final discussion proposes areas of research that will aid surgeons and multidisciplinary teams in applying neoadjuvant strategies to pancreatic cancer.