Locally Advanced Pancreatic Cancer: Is There a Role for Neoadjuvant Chemo-Radiation? A Case Report and Literature Review

Context Pancreatic cancer resection represents the only chance of cure but it can be performed only in localized cancer. Herein we report the case of a patient with locally advanced pancreatic cancer who underwent neoadjuvant chemo-radiation therapy followed by surgical resection with no residual tumour (R0). Case report A 50-year-old man was referred to our team for the presence of jaundice. A CT showed a mass in the head of the pancreas with an encasement of at least 50% of the circumference of the superior mesenteric vein (SMV). The involvement of the SMV was considered a relative contraindication to surgery. The patient underwent an ERCP and a biliary stent was left in the common bile duct. Diagnosis of pancreatic ductal adenocarcinoma was done after a trans-abdominal US-guided fine-needle aspiration. A neoadjuvant chemo-radiation treatment was then offered to the patient who accepted. A pre-treatment staging PET showed an high metabolic activity area in the pancreatic head region and a quite similar area projected above the IV hepatic segment. The patient started 8 cycles of chemotheraphy with gemcitabine and oxaliplatan then he underwent a chemoradiation treatment of 6 week. A re-staging was then performed. CT revealed a decrease of the size of the tumour. There was no involvement of the SMV. PET showed a completely remission of disease. In relation to these changes the patient was considered for surgical resection R0. A pylorus-preserving pancreaticoduodenectomy with tangential resection of the SMV was performed. Postoperative course was uneventful. Histological examination of the resected specimen showed microscopic ductal adenocarcinoma of the pancreas without neoplastic involvement of the lymph nodes; resection margins and vein wall tissue were cancer free (R0). At 19 months from diagnosis the patient is alive and well, and he remains free of recurrence or metastatic disease. Conclusions Even if, nowadays, neoadjuvant treatment is not a standard of cure in pancreatic cancer, studies have demonstrated local control in 87 to 100 percent of patients. According to the evidence of our and other cases we suggest to perform neoadjuvant chemo-radiation treatment in all patients affected by "borderline resectable" pancreatic cancer.