Borderline-resektables Pankreaskarzinom. Exploration? Neoadjuvante Therapie?

Pancreatic cancer depicts a high tumor burden and is estimated to be the second most tumor-related cause of death by the year 2030 due to its increasing incidence. The most important therapy goal in a potentially curative situation is to achieve a R0-resection. R0-resections are limited due to the low proportion of primary resectable patients (10-20 %). Besides, patients with distant metastasis (50-60 %) at primary diagnosis, borderline resectable patients can receive neoadjuvant treatment in order to downstage the tumor and increase the chance for a R0-resection. For the definition of borderline resectability contact to arterial and venous vessels is an important factor. This is outlined in various definitions and guidelines. However, CTscans have limitations in evaluating local tumor growth and involvement of vessels which can be over- as wells as underestimated. In order to decrease the number of exploratory laparotomies and increase the number of R0-resections neoadjuvante therapy has been introduced in patients with borderline resectable pancreatic cancer. Secondary resectability has thereby been demonstrated in retrospective studies in 50 % of the patients. The highest resection rates were achieved after neoadjuvant treatment with FOLFIRINOX (approx. 60 %). Here, neoadjuvant FOLFIRINOX treatment showed an independent prognostic factor for better long-term survival. In addition, R0-resection rates were higher after neoadjuvant treatment, with the highest rates reached after FOLFIRINOX. As CT-scan is limited in evaluating local tumor growth after neoadjuvant therapy, all patients should receive exploratory laparotomy liberally and attempt an oncological radical resection (R0-resection) due to its benefits on long-term outcome.