Neoadjuvant chemoradiotherapy has a potential role in pancreatic carcinoma

Abstract

Pancreatic cancer has an extremely poor prognosis, only a small minority of patients undergo a resection with curative intent. Chemotherapy and/or radiochemotherapy may improve this by prolonging survival or disease-free interval and improving resectability and the proportion of microscopically complete (R0) resections. With regard to prolonging survival, both in the postoperative adjuvant setting and in locally advanced disease, chemotherapy has a positive but limited effect on survival and may be considered standard. The role of postoperative adjuvant radiochemotherapy remains debatable. For improving resectability/proportion of R0 resections, many studies suggest that the proportion of patients undergoing a resection during exploration and the proportion of R0 resections increase after neoadjuvant radiochemotherapy. This may improve the prognosis of patients with a resectable or borderline resectable pancreatic carcinoma. The effect of neoadjuvant radiochemotherapy, if any, is modest. The search for better combinations, including targeted therapy, must continue. The interpretation of single-arm studies is hampered by (selection) biases. The reporting of pathology and study endpoints should be internationally standardized. To avoid biases in studies of patients with (borderline) resectable tumours, prospective parallel registration of all patients referred for surgery would help. Ultimately, randomized controlled phase III trials should establish the role of neoadjuvant radiochemotherapy. Thus, neoadjuvant radiochemotherapy has a potential benefit in resectable and borderline resectable pancreatic cancer, but better combinations are warranted.

Dosimetric Advantages of Midventilation Compared With Internal Target Volume for Radiation Therapy of Pancreatic Cancer

“…Radiochemotherapy has a potential benefit for resectable and borderline resectable pancreatic cancer because it can improve tumor resectability (1). However, owing to geometric uncertainties, large margins around the tumor are used in radiation therapy of pancreatic tumors, resulting in higher dose to surrounding organs at risk (OARs) and therefore possibly more toxicity.…”

Impact of CYP2C19 polymorphism on the pharmacokinetics of nelfinavir in patients with pancreatic cancer

“…Combined chemotherapy and radiotherapy have been widely used as an adjunct to treat pancreatic cancer before or after surgery, or as definitive treatment for unresectable locally advanced disease . The standard of care is gemcitabine‐based chemotherapy combined with radiotherapy . Unfortunately, the advantages of such chemo‐radiotherapy in patients with pancreatic cancer are limited due to the rapid onset of radioresistance.…”

Optimize radiochemotherapy in pancreatic cancer: PARP inhibitors a new therapeutic opportunity

“…The standard of care as postoperative adjuvant therapy in this tumour setting is chemotherapy with Gemcitabine or 5‐FU. In the USA however, the combination of these drugs with radiotherapy is widely used, following large, single‐institute studies from the Johns Hopkins University and the Mayo Clinic, and a Gastro‐Intestinal Tumour Study Group (GITSG) trial performed in the early 1980s (van Tienhoven et al., 2011). Unfortunately neither the small GITSG trial (Kalser and Ellenberg, 1985), nor the randomized studies from the European Organisation for Research and Treatment of Cancer (EORTC) (Smeenk et al., 2007; Klinkenbijl et al., 1999), nor the ESPAC‐01 trial (Neoptolemos et al., 2004) validated this scheme.…”

“…In summary, after R0 resection the current evidence supports the use of adjuvant chemotherapy rather than chemoradiotherapy followed by chemotherapy, even if the latter is regarded as the standard of care in North America. After R1 resection, adjuvant chemoradiotherapy should be considered (van Tienhoven et al., 2011).…”