Primarily resectable pancreatic adenocarcinoma – to operate or to refer the patient to an oncologist?

[Display omitted] •The risk of micrometastases formation at the time of diagnosis in resectable disease is very high.•New chemotherapy regimens (ESPAC-4, Prodige 24) offer improved survival in the adjuvant setting.•Adjuvant chemotherapy was shown to improve survival even if delayed >12 weeks.•A large, recently published metaanalysis favors the neoadjuvant approach in resectable disease.•Preliminary results of the PREOPANC-1 trial show superior outcomes with the neoadjuvant strategy. The aim of this work is to investigate the optimal therapeutic sequence of resectable pancreatic cancer – primary surgery with adjuvant therapy or neoadjuvant followed by resection. Application of the neoadjuvant approach in routine treatment of pancreatic cancer is rapidly growing every year, despite the lack of final results from randomized trials. Recent advancements in the adjuvant therapy, due to the more effective chemotherapy regimens, favor the upfront surgery strategy. On the other hand, theoretical background and metaanalyses favor the neoadjuvant strategy. Currently, primary resection with adjuvant chemotherapy remains the standard approach in resectable pancreatic cancer, but the first recommendations considering the neoadjuvant approach as an option seem to arise among the scientific societies with a global impact. Preliminary results of Prodige 24 study and PREOPANC-1 trial demonstrates that both options are worth further evaluation in clinical trials. Their results should soon provide more answers to this important clinical questions.