Borderline Resectable Pancreatic Cancer: Neoadjuvant Chemotherapy, Stereotactic Body Radiotherapy (SBRT), and Surgery

Pancreatic adenocarcinoma remains a highly fatal cancer, especially when classified as borderline resectable, characterized by limited involvement of surrounding major blood vessels that challenges but does not absolutely preclude curative surgical resection. We report the case of a 65-year-old male with a history of smoking who presented with progressive, painless jaundice, pruritus, and weight loss over 15 months. Imaging revealed intrahepatic biliary dilation, a distal common bile duct stricture, and a mass in the pancreatic head with peripancreatic lymphadenopathy. Endoscopic intervention confirmed malignant features, and stenting was performed. Subsequent cross-sectional imaging demonstrated a 3.5 cm pancreatic head mass with a 180-degree encasement of the superior mesenteric artery and aortic abutment. Carcinoembryonic antigen 19-9 (CA 19-9) was markedly elevated at 12,000 U/mL. Endoscopic ultrasound-guided biopsy confirmed pancreatic ductal adenocarcinoma. Immunohistochemical staining was positive for cytokeratin 7 and negative for CK20, supporting the pancreatic origin. The patient received six cycles of neoadjuvant-modified folinic acid (leucovorin), fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX), resulting in radiographic tumor shrinkage to 2.4 cm and a biochemical response. Stereotactic body radiation therapy (35 Gy in five fractions) focused on the vascular margin. Surgical resection via pylorus-preserving pancreaticoduodenectomy achieved R0 margins without metastasis. Postoperative recovery was uncomplicated, and the final pathology showed ypT2N1 disease with a 60% treatment response. Adjuvant chemotherapy with gemcitabine and capecitabine was initiated, and tumor markers normalized on follow-up. This case highlights the importance of a multidisciplinary, staged treatment approach in managing borderline resectable pancreatic cancer to optimize resectability and long-term outcomes.