When to Operate After Neoadjuvant Therapy for Borderline Resectable Pancreatic Cancer: A Critical Review and Multidimensional Decision Framework.

Authors

WaiSan Ho, WenChao Xu, JianLu Zhang, JunChao Guo

Published in

Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. Pages 102640. Oct 14, 2026. Epub Oct 14, 2026.

Abstract

Surgical timing after neoadjuvant therapy for borderline resectable pancreatic cancer remains difficult because post-treatment imaging may not reliably distinguish residual tumor from fibrosis, whereas tumor biology and patient fitness strongly influence surgical benefit.
We performed a critical narrative review of studies and guidelines addressing surgical timing, radiological response, tumor-marker dynamics, pathological response, and physiological readiness after neoadjuvant therapy for borderline resectable pancreatic cancer.
Current evidence supports a multidimensional approach rather than reliance on anatomical imaging alone. Informative tumor-marker trajectories, especially carbohydrate antigen 19-9 when reliable and alternative markers such as Duke pancreatic monoclonal antigen type 2 when carbohydrate antigen 19-9 is non-informative, are central to assessing systemic disease control. Selective use of liver magnetic resonance imaging, diffusion-weighted magnetic resonance imaging, and positron emission tomography-based modalities may help clarify discordant scenarios or detect occult metastatic disease. Patient fitness, including performance status, nutritional reserve, organ function, and recovery from treatment-related toxicity, remains essential before exploration.
Surgical timing after neoadjuvant therapy for borderline resectable pancreatic cancer should integrate biology, anatomy, and patient condition. A biology-first multidisciplinary framework may help avoid futile pancreatectomy while preserving timely surgical opportunities for appropriate candidates.

PMID:
42874796
Bibliographic data and abstract were imported from PubMed on 15 Oct 2026.

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