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World J Gastroenterol. Mar 7, 2014; 20(9): 2255-2266
Published online Mar 7, 2014. doi: 10.3748/wjg.v20.i9.2255
Management of borderline and locally advanced pancreatic cancer: Where do we stand?
Jin He, Andrew J Page, Matthew Weiss, Christopher L Wolfgang, Joseph M Herman, Timothy M Pawlik
Jin He, Andrew J Page, Matthew Weiss, Christopher L Wolfgang, Timothy M Pawlik, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, United States
Joseph M Herman, Department of Radiation Oncology, Johns Hopkins Hospital, Baltimore, MD 21287, United States
Author contributions: All authors contributed equally to the production of this manuscript.
Correspondence to: Timothy M Pawlik, MD, MPH, PhD, Professor, Department of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 688, Baltimore, MD 21287, United States. tpawlik1@jhmi.edu
Telephone: +1-410-5022387 Fax: +1-410-5022388
Received: October 28, 2013
Revised: December 10, 2013
Accepted: January 14, 2014
Published online: March 7, 2014
Abstract

Many patients with pancreas cancer present with locally advanced pancreatic cancer (LAPC). The principle tools used for diagnosis and staging of LAPC include endoscopic ultrasound, axial imaging with computed tomography and magnetic resonance imaging, and diagnostic laparoscopy. The definition of resectability has historically been vague, as there is considerable debate and controversy as to the definition of LAPC. For the patient with LAPC, there is some level of involvement of the surrounding vascular structures, which include the superior mesenteric artery, celiac axis, hepatic artery, superior mesenteric vein, or portal vein. When feasible, most surgeons would recommend possible surgical resection for patients with borderline LAPC, with the goal of an R0 resection. For initially unresectable LAPC, neoadjuvant should be strongly considered. Specifically, these patients should be offered neoadjuvant therapy, and the tumor should be assessed for possible response and eventual resection. The efficacy of neoadjuvant therapy with this approach as a bridge to potential curative resection is broad, ranging from 3%-79%. The different modalities of neoadjuvant therapy include single or multi-agent chemotherapy combined with radiation, chemotherapy alone, and chemotherapy followed by chemotherapy with radiation. This review focuses on patients with LAPC and addresses recent advances and controversies in the field.

Keywords: Pancreas, Locally advanced, Chemotherapy, Radiation, Irreversible electroporation, Pancreatic cancer

Core tip: While the management of resectable patients is surgery (with or without neoadjuvant therapy), and the management of grossly metastatic patients is palliative with systemic chemotherapy with or without radiation, there is an intermediate subset of patients with locally advanced disease which is less straightforward. This review focuses on this unique population of patients with locally advanced pancreatic adenocarcinoma and addresses recent advances and controversies in this field.