Neoadjuvant therapy for pancreatic ductal adenocarcinoma: Opportunities for personalized cancer care

Table 1 Opportunities for personalized care during neoadjuvant therapy for pancreatic cancer

Concept	Description	Examples	Outcome
Anatomic staging	Characterization of local extent and vascular involvement of tumor	Locally advanced/unresectable; Borderline resectable; Potentially resectable	Anatomic staging can influence the recommended duration and components (e.g., preoperative radiation) of neoadjuvant therapy
Molecular staging	Identification of tumor/germline genetic and molecular markers	BRCA mutations; Mismatch repair-deficiency; Molecular markers	Specific tumor/germline mutations may identify opportunity for targeted therapies (e.g., immunotherapy, PARP inhibitors) Standard chemotherapy may be influenced by molecular markers (e.g., resistance/sensitivity to traditional flouropyridamine or gemcitabine-based therapy)
Dynamic staging	Measuring biochemical, radiographic, and histologic response of the tumor to neoadjuvant therapy	Carbohydrate antigen 19-9; Response evaluation criteria in solid tumors response; Pathologic response	Measuring response to neoadjuvant therapy can influence treatment strategies (e.g., changing neoadjuvant regimen, use of radiation, recommendations for adjuvant therapy)

Table 2 Anatomic staging of localized pancreatic ductal adenocarcinoma as defined by the 2008 AHPBA/SSO/SSAT consensus guidelines

	Resectable	Borderline	Locally advanced
SMV-PV	Uninvolved with tumor with clear fat planes around vessels	Abutment, encasement, or occlusion of short segment of vein	Occlusion, thrombosis, or encasement extending several centimeters
SMA	Uninvolved	Tumor abutment < 180°	Tumor abutment > 180° (encasement) or thrombosis of artery
Celiac axis	Uninvolved	Uninvolved celiac axis; short segment encasement or abutment of common hepatic artery may be amenable to resection and reconstruction	Abutment or encasement of celiac axis indicates unresectability

SMV: Superior mesenteric vein; PV: Portal vein; SMA: Superior mesenteric artery.