Treatments for borderline resectable pancreatic cancer

You may be offered the following treatments for borderline resectable pancreatic cancer. Borderline resectable means it is unclear whether the cancer can be removed entirely through surgery because cancer has grown into or around major blood vessels surrounding the pancreas.

Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan. They will use imaging tests such as a PET scan, an MRI or a CT scan throughout your treatment to monitor how the cancer is responding and if the cancer has become resectable. How long you have these treatments for before surgery depends on which vessels are affected and by how much, and how the tumour responds to cancer treatment.

If the tumour never becomes resectable, your healthcare team will transition to giving you treatments for unresectable pancreatic cancer.

Chemotherapy uses drugs to destroy cancer cells. Chemotherapy is usually the first treatment for borderline resectable pancreatic cancer. It is used to try to shrink the tumour so that it can be surgically removed (called neoadjuvant chemotherapy).

If you have surgery to remove borderline resectable pancreatic cancer, you will likely also have chemotherapy after surgery (called adjuvant chemotherapy) to lower the chance that cancer will come back.

The most common chemotherapy drug combinations used for borderline resectable pancreatic cancer are:

• FOLFIRINOX – irinotecan, oxaliplatin, fluorouracil (also called 5-fluorouracil or 5-FU) and leucovorin
• gemcitabine and nab-paclitaxel

If you cannot have these drug combinations, you may have gemcitabine or fluorouracil with leucovorin on their own.

You may also have gemcitabine and fluorouracil if you have adjuvant chemotherapy.

Find out more about chemotherapy for pancreatic cancer.

Chemoradiation is chemotherapy and radiation therapy given during the same time period.

If you have surgery for borderline resectable pancreatic cancer and didn’t have radiation therapy before surgery, you may be offered chemoradiation after surgery (called adjuvant chemoradiation) instead of chemotherapy if there are cancer cells in the margin removed along with the tumour (called positive surgical margins).

If the tumour does not respond to neoadjuvant chemotherapy, you may be offered neoadjuvant chemoradiation to try to shrink the tumour. This treatment is rarely offered because borderline resectable tumours that do not respond to chemotherapy often grow and become unresectable before a second-line therapy such as chemoradiation can be tried.

Chemoradiation is usually given with fluorouracil or gemcitabine.

Radiation therapy uses high-energy rays or particles to destroy cancer cells. You may be offered external radiation therapy on its own or with chemotherapy as chemoradiation to try to shrink a tumour that didn't respond to neoadjuvant chemotherapy.

If you have borderline resectable pancreatic cancer and didn’t have radiation therapy before surgery, you may be offered radiation therapy on its own or as part of chemoradiation after surgery (called adjuvant radiation therapy).

Stereotactic body radiation therapy (SBRT) is a type of external radiation therapy that may be used.

Find out more about radiation therapy for pancreatic cancer.

If neoadjuvant therapy shrinks a borderline resectable tumour enough that your surgeon thinks they can remove the tumour completely and reconstruct any vessels that may be affected, you will be offered surgery. The type of surgery and amount of tissue that needs to be removed depends on several factors about the cancer including the size of the tumour and where in the pancreas the tumour is located.

A Whipple procedure( also called a pancreaticoduodenectomy) is done to remove the head of the pancreas and surrounding structures. A Whipple procedure can be used for borderline resectable pancreatic cancer in the head of the pancreas.

A modified Whipple procedure( also called a pylorus-preserving pancreaticoduodenectomy) removes all the same tissues as the Whipple procedure except for the pylorus (the part of the stomach that connects to the small intestine). You may have a modified Whipple procedure for borderline resectable pancreatic cancer in the head of the pancreas.

A distal pancreatectomy is done to remove the tail and part of the body of the pancreas as well as lymph nodes around the pancreas. It is used for borderline resectable pancreatic cancer that is in the tail or body of the pancreas.

A total pancreatectomy removes all the same structures as the Whipple procedure but removes the entire pancreas instead of just the head. It is uncommon to have a total pancreatectomy. You will likely only have a total pancreatectomy in the rare case that the location of the tumour makes it impossible for the surgeon to remove it and preserve other parts of the pancreas.

As part of surgery for borderline resectable pancreatic cancer, your surgeon may also remove some of the blood vessels around the pancreas and reconstruct others.

Find out more about surgery for pancreatic cancer.

Talk to your doctor about clinical trials open to people with pancreatic cancer in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.