Borderline Resectable Pancreatic Cancer: Concepts and Controversies

Pancreatic cancer is a lethal malignancy which is increasing in incidence. Surgical resection offers the best chances of cure for a potentially resectable adenocarcinoma of pancreas which can be supplemented by appropriate adjuvant treatment further. However, 40% of the cases are diagnosed with a distant metastasis at presentation and the remaining 30- 40% are diagnosed as a locally advanced and unresectable. The definition of resectability has been debatable and the term borderline resectable pancreas was introduced. The optimal approaches to manage these tumors are controversial and not yet standardised. While these tumors may be resectable with high probability of incomplete resection, if they are not downstaged with prior neoadjuvant chemotherapy or chemoradiotherapy. Neoadjuvant chemotherapy with single agent or with multiple agents with or without concurrent radiotherapy have been tried since ages and these modalities have wide range of conversion to R0 resection ranging from 4%- 80%. Majority of the patients despite curative R0 resection require adjuvant chemotherapy either alone or in combination with radiotherapy. This review discusses the controversies related to the management of borderline adenocarcinoma pancreas.