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Pancreatic cancer (PDAC) is an aggressive tumor type associated with development of micrometastasis at an early stage. In attempt to eradicate disseminated disease, neoadjuvant therapy has been explored in patients with resectable and borderline resectable PDAC. In large retrospective studies, neoadjuvant therapy was associated with better survival compared with upfront surgery. Previously, trials more commonly used radiotherapy (RT) with small doses of chemotherapy as radiosensitizers. Recent studies, however, have incorporated full systemic doses of chemotherapy with or without RT before surgery with the hope of achieving adequate systemic chemotherapy coverage and improving survival. Several phase II trials have shown encouraging clinical benefits using the neoadjuvant approach. Large cooperative group studies are exploring the role of neoadjuvant treatment with newer combination chemotherapy regimens and modern RT techniques, which will provide more evidence regarding the utility of this approach.

A 59-year-old woman presented with borderline resectable pancreatic adenocarcinoma involving the neck and body of the pancreas. She was treated with systemic chemotherapy followed by chemoradiation, with subsequent downstaging of the tumor by imaging. Subsequent resection had negative margins and negative lymph nodes with only microscopic disease present in the tumor specimen. Neoadjuvant therapy is controversial but could play a role in borderline resectable disease by allowing for higher chance of negative margins at surgery and increasing the chance for cure in these patients. Microscopic disease at time of resection is rare.