Table 1 Inclusion and exclusion criteria

• Histology-proven, resectable adenocarcinoma of the pancreatic head/uncinate process with a tumor size greater 2 cm (≥cT2) and/or close contact to the superior mesenteric vessels (≤3 mm in preoperative staging).

• Age ≤ 18 years

• Recurrent disease

• HInfiltration of extrapancreatic organs (except duodenum and transverse colon)

• HNo evidence of metastasis to distant organs (liver, peritoneum, lung, others).

• Persistent cholestasis/cholangitis despite adequate biliary stenting

• Serum creatinine level ≤ 3.0 mg/dl

• HGastric outlet obstruction, especially in the event of endoscopically evidenced tumor invasion into the gastroduodenal mucosa.

• HSerum total bilirubin level ≤ 3.0 mg/dl in the absence of biliary obstruction (In the event of biliary obstruction, patients allocated to the CRT group must undergo interventional endoscopy or percutaneous drainage for biliary decompression. Post-interventionally, bilirubin levels should be ≤ 3.0 mg/dl before patients are subjected to CRT. In control patients undergoing upfront surgery, serum total bilirubin levels ≤ 10.0 mg/dl are tolerated, unless clinical and laboratory signs of severe cholangitis take place. Patients with serum total bilirubin level > 10.0 mg/dl undergo preoperative biliary decompression, preferentially by interventional endoscopy)

• Tumor specific pre-treatment

• History of gastrointestinal perforation, e.g. perforated colonic diverticulitis, abdominal abscess or intestinal fistula within 6 months prior to potential study participation

• Radiographic evidence of severe portal hypertension/cavernomatous transformation that may, at the discretion of the participating investigators, hamper surgery

• Other concurrent malignancies except for basal cell cancer of the skin and in-situ cervical cancer, Premalignant hematologic disorders, e.g. myelodysplastic syndrome

• White blood cell count ≥ 3.5 × 10⁹/ml, platelet count ≥ 100 × 10⁹/ml

• Severe organ dysfunctions (e.g. Liver cirrhosis ≥ Child B; Cardio-pulmonal diseases (NYHA ≥ III, arrhythmia Lown III/IV, global respiratory insufficiency); Ascites; Acute pancreatitis; bleeding diathesis, coagulopathy, need for full-dose anticoagulation or INR > 1.5; other severe diseases that might prevent completion of the treatment regimen)

• HAbility to understand and willingness to consent to formal requirements for study participation

Written informed consent

• Chronic infectious diseases, especially immune deficiency syndromes, e.g. HIV infection, active tuberculosis within 12 months prior to potential study participation

• History of severe neurologic disorders, e.g. cerebrovascular ischemia

• History of prior deep venous thrombosis or pulmonary embolism

• Pregnant or nursing women are ineligible and patients of reproductive potential must agree to use an effective contraceptive method during participation in this trial and for 6 months following the trial

• Serious medical, psychological, familial, sociological or geographical conditions or circumstances potentially hampering compliance with the study protocol and follow-up

Participation in other clinical trials during the last 6 months before allocation to trial