Recent developments in neoadjuvant and adjuvant treatment of pancreatic cancer

BackgroundDespite the curative intent of surgical resection, pancreatic ductal adenocarcinoma (PDAC) even in localized stages has avery poor prognosis (5-year median overall survival <= 10%) due to the aggressive tumor biology with ahigh potential to develop metastatic disease.ObjectiveThis article presents the current concepts for systemic treatment in localized, non-metastatic PDAC.MethodsThis article is based on aselective literature search in the PubMed database and recent congress abstracts concerning adjuvant and neoadjuvant treatment of PDAC.ResultsWith the introduction and further refinement of effective adjuvant systemic chemotherapy, the prognosis of resectable PDAC has been consecutively improved, whereas (chemo)radiotherapy concepts have not shown additional benefits. For selected patient subgroups (e.g. PS-ECOG0, age <70years) combination chemotherapy with the modified FOLFIRINOX regimen is considered the current standard treatment in the adjuvant setting. All other patients should receive adjuvant chemotherapy with gemcitabine or a5-FU-based systemic treatment regimen over 6months after surgical resection. Due to limited access to effective postoperative systemic treatment (only approximately 50% of resected patients receive an adjuvant chemotherapy) and the potential downsizing effect with an increase in the R0 resection rate, current clinical trials are evaluating neoadjuvant concepts with modern combination chemotherapy regimens (FOLFIRINOX, gemcitabine/nab-paclitaxel) in various localized stages of PDAC (resectable, borderline resectable, primarily nonresectable); however, this is not yet standard treatment outside clinical trials.ConclusionAn effective perioperative systemic treatment is nowadays an essential part of the multidisciplinary treatment strategy for localized PDAC.