Background. Low resectability rate and high locoregional recurrence are major factors contributing to the failure of surgical treatment for localized pancreatic adenocarcinoma. A Phase II study involving preoperative 5‐fluorouracil (5‐FU) and mitomycin C and radiation therapy was evaluated. Methods. Thirty‐one patients with biopsy‐proven carcinoma (24, head of pancreas; 2, body; 5 duodenum) were treated with preoperative radiation therapy, 5040 cGy (180 cGy/fraction, 5 days/week), concurrent with 5‐FU, 1000 mg/m2/day continuous infusion (days 2–5, 28–32) and mitomycin C 10mg/m2 bolus (day 2). Ten patients had previous laparotomy or bypass surgery and were deemed unresectable; 21 had percutaneous, endoscopic retrograde choleangiopancreatic, or transhepatic stent biopsies. Results. Toxicity included neutropenic fever (2 patients), biliary sepsis (2 patients), and nausea and vomiting requiring total parenteral nutrition. One patient died of biliary sepsis before completion of chemoradiation and 11 patients showed evidence of metastatic disease (clinical or occult). Resectability rate was 38% (10/26) for pancreatic carcinoma and 80% (4/5) for duodenal carcinoma. Pathology of the resected specimens revealed extensive necrosis and hyalinization with clear margins in all cases. Lymph node metastases were found in one case of pancreatic carcinoma. The four resected duodenal carcinomas contained no residual tumor in the specimens. At a median follow‐up of 29 months, the median survival time for those with pancreatic carcinoma was not yet reached in the resection group and was 8 months in the nonresection group. The corresponding actuarial 5‐year survival rates were 58% and 0%, respectively. Conclusions. Neoadjuvant chemoradiation therapy was given safely to patients with pancreatic and duodenal carcinoma. It facilitated complete resection in 38% of patients with pancreatic carcinoma and 80% of those with duodenal carcinoma. A significant downstaging of positive margins and regional lymph nodes occurs as a result of preoperative chemoradiation.

BackgroundDeep inspiration breath hold (DIBH) reduces heart and left anterior descending artery (LAD) dose during left-sided breast radiation therapy (RT); however there is limited information about which patients derive the most benefit from DIBH. The primary objective of this study was to determine which patients benefit the most from DIBH by comparing percent reduction in mean cardiac dose conferred by DIBH for patients treated with whole breast RT ± boost (WBRT) versus those receiving breast/chest wall plus regional nodal irradiation, including internal mammary chain (IMC) nodes (B/CWRT + RNI) using a modified wide tangent technique. A secondary objective was to determine if DIBH was required to meet a proposed heart dose constraint of Dmean < 4 Gy in these two cohorts.MethodsTwenty consecutive patients underwent CT simulation both free breathing (FB) and DIBH. Patients were grouped into two cohorts: WBRT (n = 11) and B/CWRT + RNI (n = 9). 3D-conformal plans were developed and FB was compared to DIBH for each cohort using Wilcoxon signed-rank tests for continuous variables and McNemar’s test for discrete variables. The percent relative reduction conferred by DIBH in mean heart and LAD dose, as well as lung V20 were compared between the two cohorts using Wilcox rank-sum testing. The significance level was set at 0.05 with Bonferroni correction for multiple testing.ResultsAll patients had comparable target coverage on DIBH and FB. DIBH statistically significantly reduced mean heart and LAD dose for both cohorts. Percent reduction in mean heart and LAD dose with DIBH was significantly larger in the B/CWRT + RNI cohort compared to WBRT group (relative reduction in mean heart and LAD dose: 55.9 % and 72.1 % versus 29.2 % and 43.5 %, p < 0.02). All patients in the WBRT group and five patients (56 %) in the B/CWBRT + RNI group met heart Dmean <4 Gy with FB. All patients met this constraint with DIBH.ConclusionsAll patients receiving WBRT met Dmean Heart < 4 Gy on FB, while only slightly over half of patients receiving B/CWRT + RNI were able to meet this constraint in FB. DIBH allowed a greater reduction in mean heart and LAD dose in patients receiving B/CWRT + RNI, including IMC nodes than patients receiving WBRT. These findings suggest greatest benefit from DIBH treatment for patients receiving regional nodal irradiation.

Long-term follow-up confirms that local excision and radiation therapy is of value in patients with mobile tumors of the rectum. It suggests that this treatment can be offered to those patients who refuse a colostomy or are medically compromised and may be an acceptable option for selected patients with T2 or T3, mobile adenocarcinomas of the rectum.

BackgroundIn limited metastatic burden of disease, stereotactic body radiotherapy (SBRT) has been shown to achieve high local control rates. It has been hypothesized that SBRT may translate to a better quality of life by delaying the need for systemic chemotherapy and possibly increasing survival. There is limited published literature on the efficacy of SBRT in limited nodal metastases. The primary aim is to review institutional outcomes of patients with solitary or oligometastatic lymph nodes treated with SBRT.MethodsA retrospective study of patients treated with SBRT to metastatic lymph nodes (March 2010–June 2015) was conducted. Endpoints of this study were local control (LC), chemotherapy-free survival (CFS) following SBRT, toxicities, progression free survival (PFS), and overall survival (OS).ResultsEighteen patients with a mean age of 65 years underwent SBRT to metastatic lymph nodes. Median follow-up was 33.6 months. There were four hepatocellular carcinoma, seven colorectal, four pancreatic, one esophageal, one gallbladder and one lung primary. Eleven (61%) patients had lymph node metastases at initial presentation of metastatic disease. Seven patients (39%) had systemic therapy prior to SBRT, with five patients receiving two lines of chemotherapy. Eight patients had solitary metastatic disease at the time of radiotherapy. All patients had <5 metastases. Median size of lymph node metastases was 1.95 cm (range: 0.8–6.2 cm). RT doses were 31 to 60 Gy in four to ten fractions, with 44% of patients receiving 35 Gy in 5 fractions. At 1 year, LC was 94% and CFS from SBRT was 60%. One-year PFS and OS were 39% and 89% respectively. There were no grade 3 or higher toxicities.ConclusionsIn this single institution study, SBRT to oligometastatic lymph nodes provided excellent LC and a moderate chemotherapy-free interval with minimal toxicities. Disease progression remains prominent in these patients and larger studies are warranted to identify those who benefit most from SBRT.