Total Neoadjuvant Therapy in Localized Pancreatic Cancer: Is More Better?

Simple Summary: Pancreatic cancer is challenging to treat due to late diagnosis and limited options. Surgery, the main treatment, often leads to poor long-term outcomes, prompting exploration of alternative approaches like neoadjuvant therapy (NAT) and total neoadjuvant therapy (TNT). While NAT aims to improve surgical success and overall survival, there is room for enhancement, leading to consideration of neoadjuvant strategies combining full-dose chemotherapy and radiotherapy in TNT. TNT, integrating chemotherapy and radiotherapy before surgery, could increase the likelihood of successful surgery and cure for locally advanced cases. This article explores different TNT strategies, categorized based on radiotherapy techniques, offering a thorough analysis of their effectiveness in borderline resectable and locally advanced pancreatic cancer. The central question remains: does more treatment before surgery always yield better results? Pancreatic ductal adenocarcinoma (PDAC) poses a significant challenge in oncology due to its advanced stage upon diagnosis and limited treatment options. Surgical resection, the primary curative approach, often results in poor long-term survival rates, leading to the exploration of alternative strategies like neoadjuvant therapy (NAT) and total neoadjuvant therapy (TNT). While NAT aims to enhance resectability and overall survival, there appears to be potential for improvement, prompting consideration of alternative neoadjuvant strategies integrating full-dose chemotherapy (CT) and radiotherapy (RT) in TNT approaches. TNT integrates chemotherapy and radiotherapy prior to surgery, potentially improving margin-negative resection rates and enabling curative resection for locally advanced cases. The lingering question: is more always better? This article categorizes TNT strategies into six main groups based on radiotherapy (RT) techniques: (1) conventional chemoradiotherapy (CRT), (2) the Dutch PREOPANC approach, (3) hypofractionated ablative intensity-modulated radiotherapy (HFA-IMRT), and stereotactic body radiotherapy (SBRT) techniques, which further divide into (4) non-ablative SBRT, (5) nearly ablative SBRT, and (6) adaptive ablative SBRT. A comprehensive analysis of the literature on TNT is provided for both borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), with detailed sections for each. [ABSTRACT FROM AUTHOR]