Single-Institution Outcomes of Neoadjuvant Gemcitabine and Nab-Paclitaxel Combination in Borderline Resectable Pancreatic Adenocarcinoma: A Three-Year Retrospective Audit

Background Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive and difficult-to-treat cancer, with five-year survival rates still low despite advances in treatment. Borderline resectable pancreatic cancer (BRPC) is associated with a high risk of margin-positive resection and early systemic relapse when treated with upfront surgery alone. Neoadjuvant systemic therapy is therefore recommended to improve resectability and oncologic outcomes. Although combination chemotherapy with 5-fluorouracil (5-FU), leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) is effective, its toxicity limits use in routine clinical practice. Gemcitabine plus nab-paclitaxel (GnP) represents a commonly used alternative with a more favourable tolerability profile. Methods This retrospective audit included consecutive adult patients with histologically confirmed BRPC treated with neoadjuvant GnP at a single tertiary care center between January 2022 and December 2024. Borderline resectability was defined using National Comprehensive Cancer Network criteria, with institutional interpretation informed by international consensus recommendations. Patients received three to six cycles of gemcitabine and nab-paclitaxel according to institutional standards. Radiologic response was assessed using the standard guideline Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, with qualitative evaluation of the tumor-vessel interface guiding surgical decision-making. Surgical, pathological, toxicity, progression-free survival (PFS), and overall survival (OS) outcomes were analyzed. Results Thirty-four patients were included, with a median age of 61 years; 27 patients (79%) had Eastern Cooperative Oncology Group (ECOG) performance status (PS) 1, and seven patients (21%) had ECOG performance status 2. Partial response (PR) was observed in 14 patients (41%), stable disease (SD) in 13 patients (38%), and progressive disease (PD) in 7 patients (21%). Improvement in the tumor-vessel interface was documented in 16 patients (47%). Surgical exploration was undertaken in 22 patients (65%), and curative-intent resection was achieved in 19 patients (56%) of the overall cohort. R0 resection was achieved in 13 (68%) of resected patients. Median PFS was 14.2 months, and median OS was 22.8 months, with a three-year OS of 28%. These outcomes were consistent with previously reported neoadjuvant GnP studies and the Locally Advanced Pancreatic Cancer Cetuximab and nab-Paclitaxel Trial (LAPACT) trial experience. Conclusions Neoadjuvant gemcitabine and nab-paclitaxel combination is a feasible and effective treatment option for borderline resectable pancreatic adenocarcinoma in real-world practice. While outcomes may be inferior to those reported with FOLFIRINOX in highly selected patients, GnP provides meaningful disease control with acceptable toxicity and remains a pragmatic option when intensive regimens are unsuitable.