Institut régional du Cancer de Montpellier (ICM)
208 rue des Apothicaires 34298 Montpellier Cedex 5
Hôpitaux Universitaires Paris Nord Val de Seine (HUPNVS), Hôpital Beaujon, service d’oncologie digestive, Université Paris 7 – Denis Diderot, INSERM UMR1149, 100 boulevard du Général Leclerc, 92110 Clichy-La-Garenne, France
Locally-advanced (LA) pancreatic cancers account for one third of all pancreatic cancers. Their management has not yet reached a consensus. Gemcitabine was the single option with a median survival of 7-9 months but there is likely a future for more aggressive systemic chemotherapies using FOLFIRINOX and gemcitabine-nab-paclitaxel” currently used as standards for metastatic cancers. This option, however, is not yet validated, as for radiotherapy. Only retrospective studies are available and assess chemo- or radiotherapy with variable results in terms of median survival, probably because these studies are not randomized, and in heterogeneous populations (borderline and LA tumors). Few meta-analyses have shown median survival of superior to 15 months. Results of a phase II study comparing gemcitabine-nab-paclitaxel combination (LAPACT) and of phase III comparing FOLFIRINOX combination to gemcitabine gemcitabine (NEOPAN) should answer regarding the superiority of the association.
Chemoradiotherapy, still controversial, showed recently with the only randomized phase III trial (LAP-07) a lack of superiority of chemoradiotherapy over chemotherapy alone, but with a significantly longer time without treatment.
New opportunities for development are ongoing, especially in the field of mechanisms of resistance to chemotherapy, of peritumoral stromal response or of tumoral inhibition of the immune system, but also in the field of exome sequencing to develop new therapeutic targets The study of circulating tumor cells (CTC) as new biomarkers.
Resectability after medical treatment in LA cancers was non envisageable, but before the availability since 5 years of more efficient sytemic chemotherapies, it became an important aim in order to change a treatment said palliative in an induction treatment.
In conclusion, prognosis of LA pancreatic cancers has improved with a median survival of 15-16 months. Optimizing systemic treatment is probably the key to prognosis improvement, using prognostic tools. Including patients in therapeutic trials may be the means to answer remaining questions regarding this “intermediate” form of pancreatic cancer.