How would you treat a patient with borderline resectable pancreatic cancer with CT showing no change in tumor size after 4 cycles of neoadjuvant FOLFIRINOX?

This is a great question. We have an in-house protocol that is trying to answer this exact question with built-in, arbitrary parameters for clinical, biochemical, and radiographic response to ascertain whether or not to switch to a non-cross resistant chemotherapy regimen after 2 months of neoadjuvant FOLFIRINOX.

There are various flavors of borderline resectable pancreas cancer - anatomically borderline resectable vs. high suspicion for occult micro-metastatic disease (very high CA 19-9 level, ...

Most of the data in chemotherapy efficacy in Pancreatic Ductal Adenocarcinoma (PDAC) is in the metastatic setting. PRODIGE 4/ACCORD11 (Conroy et al., PMID 21561347) and MPACT (Von Hoff et al., PMID 24131140) phase III trials established 2 new standard-of-care in the first line treatment of PDAC. Recent studies have suggested possible different histologic subtypes of PDAC with the basal-like (GATA6 expressing) classical type tending to be chemorefractory to FOLFIRINOX.

In the phase I/II GABRINOX t...

To build upon the very thoughtful comments of both @Dr. First Last and @Dr. First Last - it is not all that uncommon to see relatively stable primary tumor size on interval CT imaging for PDAC. Some of this is post-treatment fibrotic change which is challenging to differentiate from active tumor- prime space for AI in my opinion.

For interval assessment, I would recommend a combination of pancreas protocol CT, serum biomarkers with CA 19-9 +/- CEA if elevated at baseline, and consideration for P...

Great question in a challenging subset of patients with a disease process with very poor outcomes. If no radiographic response and CA19-9 response, we would switch to Gem/Abraxane. To maximize the chance of a cure, we need both surgery and chemotherapy. COMPASS showed low expressions of GATA6 were potentially predictive of chemoresistance to FOLFIRINOX and this is being explored in NEOPANCONE.

Aung et al., PMID 29288237

Kelly et al., 2022 ASCO Gastrointestinal Cancers Symposium