For one, response evaluation after FOLFIRINOX based on CT shows poor correlation between imaging findings and tissue evaluation at surgical exploration, potentially depriving patients the chance of resection if imaging findings are evaluated for response alone. Response evaluation by cross-sectional imaging after neoadjuvant treatment is troublesome, and to some degree even unreliable 2. Although neoadjuvant therapy for locally advanced pancreatic cancer is arbitrarily being referred to as ‘downstaging’ or ‘downsizing’ by some, it is really a test of tumour responsiveness or biological aggressiveness. For borderline and locally advanced pancreatic cancer, previously considered unresectable, effective yet toxic regimens, such as the combination regimen of fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX), have made induction therapy an option. Hence, neoadjuvant chemotherapy becomes a test of biology, before proceeding to surgery. The theory is that early metastasis is most likely present at the time of diagnosis, albeit not visible on conventional imaging or by standard tests. This observation has shifted systemic treatment towards a neoadjuvant approach for borderline resectable and, more recently, for upfront resectable disease.įor resectable disease, one of the important intentions of neoadjuvant chemotherapy, in addition to increasing the rate of receipt of systemic therapy, is to avoid a major resection in patients who would develop metastasis early in the course after surgery. Outside the narrow inclusion criteria for clinical trials, up to half of all patients do not recover well enough to start, let alone complete, adjuvant treatment after surgery. Hence, although surgical resection provides the best chance of cure, multimodal treatment is essential for long-term survival 1. ![]() ![]() ![]() Pancreatic cancer is believed to be a systemic disease from the very early stages.
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