Evaluation of routine use of neoadjuvant chemo-radiotherapy for management of borderline resectable pancreatic cancer versus surgery-first approach

Background: Borderline resectable pancreatic cancer (BRPC) presents a significant treatment challenge, with an elevated likelihood of incomplete resection and early recurrence. While upfront surgery offers immediate tumor removal, neoadjuvant chemoradiotherapy (NACRT) has been proposed to improve resection outcomes by reducing tumor burden and eliminating micrometastases. The optimal treatment strategy remains a topic of ongoing discussion and disagreement.Objective: To compare the outcomes of NACRT versus upfront surgery in BRPC patients, evaluating tumor resectability intraoperatively, postoperative complications, adjuvant therapy feasibility, and one-year survival rate.Methods: A retrospective comparative study was conducted at Ain Shams University Hospitals, including 30 patients diagnosed with BRPC based on NCCN classification. Patients were subdivided into two groups: NACRT (n=15) and upfront surgery (n=15). Data on tumor resectability, R0 and pN0 resection rates, postoperative complications, and survival were analyzed. Statistical significance was set at p<0.05.Results: Tumor resectability was significantly elevated in the upfront surgery group (80.0% vs. 33.3%, p=0.010). R0 resection and pN0 rates were 100% in the NACRT group compared to 83.3% R0 resection and 33.3% pN0 rates in the upfront surgery group (p=0.999 for R0 resection, 0.029 for pN0). Postoperative complications were similar, with one case of fistula (8.3%) occurring in the upfront surgery group. All resected patients in both groups received postoperative adjuvant therapy and survived at least one year.Conclusions: Upfront surgery results in a higher initial resectability rate, while NACRT improves margin-negative resection and nodal clearance. Both strategies have distinct advantages, and patient selection should be guided by tumor characteristics and multidisciplinary evaluation. Further prospective research involving bigger participant groups and extended follow-up periods is necessitated to determine the long-term effects of NACRT on survival.