Median progression-free survival was 6.4 months in the FOLFIRINOX group and 3.3 months in the gemcitabine group (P<0.001). The objective response rate was 31.6% in the FOLFIRINOX group versus 9.4% in the gemcitabine group (P<0.001). The authors concluded that FOLFIRINOX is an option for the treatment of selleck inhibitor patients with metastatic pancreatic cancer and good performance status. There has been some interest from cooperative Inhibitors,research,lifescience,medical groups and single institutions to propose FOLFIRINOX based systemic therapy followed by chemoradiation for patients with upfront unresectable (but borderline criteria) pancreatic

cancer to potentially maximize their chance of resectability and improve survival after preoperative therapy. Though, it is important to note that beside

an excellent PS, >50% of patients in the FOLFIRINOX study had pancreatic tail tumors and the triple drug regimen was not without toxicity (especially in patients with biliary stents/ Inhibitors,research,lifescience,medical those prone to cholangitis). Katz and colleagues have published the largest to date retrospective report of 160 patients with borderline resectable pancreatic cancer (from a prospective database, 1999 -2006) (17). Of these, 125 (78%) received preoperative therapy with mostly chemotherapy followed by chemoradiation and 66 (41%) underwent PD. Twenty seven percent (18 of 66) required vascular resections and in 94% of the patients this was Inhibitors,research,lifescience,medical an R0 resection. The median survival was 40 months for patients who underwent preoperative therapy followed by surgery and 13 months for patients who did not undergo PD (p<0.001). Interestingly, the percent change in CA 19-9 over the course of preoperative therapy was associated with overall survival. When compared to patients who had a > 50% decrease in serum CA 19-9, patients with an increase in serum CA 19-9 had Inhibitors,research,lifescience,medical a greater than 2-fold risk of death (HR = 2.4, p = 0.02, 95 % CI [1.2, 4.9]). In practice, the radiographic stability (or response), patient’s tolerability to therapy Inhibitors,research,lifescience,medical and performance status as well as the Ca19-9 trend is factored into making a therapy decision. Prospective data on the role of CA19-9 as a predictive marker is needed Ceritinib LDK378 before we consider using it as a part of the ‘resectability

criteria’ in treated patients. Understandably, there is an inherent selection bias given that the prolonged course of therapy which selects for better tumor biology, though the role of radiation in this setting needs Anacetrapib further evaluation. When our systemic agents and biomarker based techniques to select patients improve, it will provide additional justification for the need for prolonged therapy prior to locoregional options. Barriers to preoperative therapy for borderline resectable cancer It is mandatory for patients with resectable or borderline resectable pancreatic cancer to proceed with a cytologic diagnosis of adenocarcinoma (via EUS-guided FNA biopsy) prior to initiating preoperative therapy (16). On rare occasion, this can lead to pancreatitis.