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Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 28, 2015; 21(8): 2281-2293
Published online Feb 28, 2015. doi: 10.3748/wjg.v21.i8.2281
New challenges in perioperative management of pancreatic cancer
Francesco Puleo, Raphaël Maréchal, Pieter Demetter, Maria-Antonietta Bali, Annabelle Calomme, Jean Closset, Jean-Baptiste Bachet, Jacques Deviere, Jean-Luc Van Laethem
Francesco Puleo, Raphaël Maréchal, Annabelle Calomme, Jean Closset, Jacques Deviere, Jean-Luc Van Laethem, Department of Gastroenterology and Digestive Oncology, Erasme Hospital, 1070 Brussels, Belgium
Francesco Puleo, Raphaël Maréchal, Annabelle Calomme, Jacques Deviere, Laboratory of Experimental Gastroenterology, Free University of Brussels, 1070 Brussels, Belgium
Pieter Demetter, Department of Pathology, Erasme Hospital, 1070 Brussels, Belgium
Maria-Antonietta Bali, Department of Radiology, Erasme Hospital, 1070 Brussels, Belgium
Jean-Baptiste Bachet, Department of Hepatogastroenterology, Pitié Salpêtrière Hospital, 75013 Paris, France
Author contributions: Puleo F conceived the design, performed the literature search, interpretation and wrote the manuscript; Maréchal R, Calomme A, Demetter P, Bachet JB, Bali MA, Devière J and Van Laethem JL participated in drafting the paper and revised critically for important intellectual content.
Supported by Grants from Fonds Erasme, ULB, Brussels (to Francesco Puleo).
Conflict-of-interest: All authors have no conflict of interest related to the manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jean-Luc Van Laethem, MD, PhD, Department of Gastroenterology and Digestive Oncology, Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070 Brussels, Belgium. jl.vanlaethem@erasme.ulb.ac.be
Telephone: +32-25-553712 Fax: +32-25-553718
Received: October 2, 2014
Peer-review started: October 3, 2014
First decision: October 29, 2014
Revised: November 14, 2014
Accepted: January 16, 2015
Article in press: January 16, 2015
Published online: February 28, 2015
Abstract

Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related death in the industrialized world. Despite progress in the understanding of the molecular and genetic basis of this disease, the 5-year survival rate has remained low and usually does not exceed 5%. Only 20%-25% of patients present with potentially resectable disease and surgery represents the only chance for a cure. After decades of gemcitabine hegemony and limited therapeutic options, more active chemotherapies are emerging in advanced PDAC, like 5-Fluorouracil, folinic acid, irinotecan and oxaliplatin and nab-paclitaxel plus gemcitabine, that have profoundly impacted therapeutic possibilities. PDAC is considered a systemic disease because of the high rate of relapse after curative surgery in patients with resectable disease at diagnosis. Neoadjuvant strategies in resectable, borderline resectable, or locally advanced pancreatic cancer may improve outcomes. Incorporation of tissue biomarker testing and imaging techniques into preoperative strategies should allow clinicians to identify patients who may ultimately achieve curative benefit from surgery. This review summarizes current knowledge of adjuvant and neoadjuvant treatment for PDAC and discusses the rationale for moving from adjuvant to preoperative and perioperative therapeutic strategies in the current era of more active chemotherapies and personalized medicine. We also discuss the integration of good specimen collection, tissue biomarkers, and imaging tools into newly designed preoperative and perioperative strategies.

Keywords: Neoadjuvant chemotherapy, Biomarkers, Preoperative strategies, Pancreatic ductal adenocarcinoma, Personalized medicine

Core tip: Adoption of preoperative treatment strategies in management of pancreatic ductal adenocarcinoma has the potential to increase resection rates and reduce relapse rates by targeting residual tumor cells and micrometastases early. The use of new, more active chemotherapy regimens such as 5-Fluorouracil, folinic acid, irinotecan and oxaliplatin and nab-paclitaxel plus gemcitabine in the neoadjuvant setting may offer an opportunity to downstage patients with borderline resectable or locally advanced disease to true curative intent R0 resection candidates. A more personalized approach in the setting of a neoadjuvant research platform, using tissue biomarkers and advanced imaging techniques to monitor treatment response could help improve our understanding of tumor biology and ultimately identify patients who could benefit from curative surgery.