A 62-year-old woman presents with progressive jaundice, weight loss, and a Courvoisier's sign. CT scan shows a 3 cm mass at the head of pancreas with dilated CBD and pancreatic duct. CA 19-9 is 850 U/mL. CT shows no vascular encasement or distant metastasis. She is deemed borderline resectable. The MOST appropriate neoadjuvant approach is:
- A FOLFIRINOX (5-FU, leucovorin, irinotecan, oxaliplatin) or gemcitabine-based chemoradiotherapy to potentially achieve clear surgical margins ✓
- B Proceed directly to Whipple's (pancreaticoduodenectomy) without neoadjuvant therapy
- C Gemcitabine monotherapy for 3 months followed by reassessment of resectability
- D Endoscopic ultrasound-guided ablation of the mass to reduce CA 19-9 levels
Correct answer: A. FOLFIRINOX (5-FU, leucovorin, irinotecan, oxaliplatin) or gemcitabine-based chemoradiotherapy to potentially achieve clear surgical margins
Explanation
For borderline resectable pancreatic ductal adenocarcinoma, neoadjuvant chemotherapy (FOLFIRINOX in fit patients or gemcitabine/nab-paclitaxel) ± chemoradiotherapy is the preferred approach per NCCN and international guidelines to improve the likelihood of achieving an R0 resection. This approach has improved the R0 resection rate and survival compared to upfront surgery in borderline cases. Gemcitabine monotherapy is inferior to FOLFIRINOX in the neoadjuvant setting. EUS ablation is not a standard treatment. Direct surgery risks R1/R2 resection in borderline cases.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.