Preoperative Chemoradiation and Pancreaticoduodenectomy for Adenocarcinoma of the Pancreas

Abstract

Chemoradiation prior to pancreaticoduodenectomy ensures that all patients who undergo resection complete multimodality therapy, avoids resection in patients with rapidly progressive disease, and allows radiation therapy to be delivered to well-oxygenated cells before surgical devascularization. Twenty-eight patients with cytologic or histologic proof of localized adenocarcinoma of the pancreatic head received preoperative chemoradiation (fluorouracil, 300 mg/m2 per day, and 50.4 Gy) with the intent of proceeding to resection; all 28 completed this preoperative therapy. Hospital admission because of gastrointestinal toxic effects was required in nine patients, yet no patient experienced a delay in operation. Restaging was performed 4 to 5 weeks after completion of chemoradiation, and five patients were found to have metastatic disease; the 23 patients without evidence of progressive disease underwent laparotomy. At laparotomy, three patients were found to have unsuspected metastatic disease, three patients had unresectable locally advanced disease, and 17 patients were able to undergo pancreaticoduodenectomy. One perioperative death resulted from myocardial infarction, and perioperative complications occurred in three patients. Histologic evidence of tumor cell injury was present in all resected specimens. Our results suggest that pancreaticoduodenectomy can be performed with a low incidence of complications after chemoradiation for localized adenocarcinoma of the pancreas.

Pathologic complete response to neoadjuvant therapy in patients with pancreatic ductal adenocarcinoma is associated with better prognosis

“…Despite significant improvements in operative techniques and mortality rates related to pancreatectomy and the advance of adjuvant chemoradiation therapy, the prognosis for patients with PDA remains unchanged in the last four decades. Neoadjuvant CRT has been increasingly used in patients with potentially resectable PDA and has been shown to improve the survival and locoregional metastatic disease [15,[20][21][22][23]. In this group of patients, the frequency of pCR in subsequent pancreatectomy specimens is largely unknown.…”

“…The pCR was defined as area of scarring in pancreatic parenchyma and/or peripancreatic soft tissue with chronic inflammation, with or without acellular mucin pools and histiocytic infiltrates, but no residual viable invasive adenocarcinoma cells in the pancreatectomy specimen. These criteria are based on the grading system for the extent of residual tumor proposed by Evans et al: grade I, little (<10%) or no tumor cell destruction is evident; grade IIa, destruction of 10%-50% of tumor cells; grade IIb, destruction of 51%-90% of tumor cells; grade III, few (<10%) viableappearing tumor cells are present; grade IV, no viable tumor cells are present; and IVM, only acellular pools of mucin, but not viable tumor cells are present [15]. Cases with either microscopic or gross viable residual tumor were staged based on the AJCC Cancer Staging Manual, 7 th edition.…”

Two Cases of Pathological Complete Response to Neoadjuvant Chemoradiation Therapy in Pancreatic Cancer

“…Very few reports have given a strict definition of pCR to NACRT in PDA. 18,19 However, Zhao et al have recently defined pCR in PDA as the presence of an area of scarring in pancreatic parenchyma and/or peripancreatic soft tissue with chronic inflammation with no residual viable invasive adenocarcinoma cells, regardless of the presence of intraductal neoplasms such as PanIN/CIS in pancreatectomy specimens, and found that patients with pCR based on these criteria had a better prognosis than other patients. 16 Zhao et al performed detailed pathological examinations after NACRT and revealed that PanIN3/CIS was present in 5/11 (45%) of pCR cases; 16 PanIN3/CIS was present in both our pCR cases.…”

“…There are some grading systems for the extent of residual tumor in PDA after CRT, 6,9,[17][18][19] but systems for assessing histological therapeutic effect have not yet been standardized. For example, Evans et al proposed criteria based on the amount of destruction of tumor cells, paying attention to acellular mucin pools, 18 whereas Le Scodan et al proposed classification based on the proportions of degenerative tumor cells present.…”

Pancreatic cancer

“…However, the impact of neoadjuvant therapy on survival is not clear. 55,56 Palliative treatment using radiation therapy with low-dose 5-FU as a radiosensitizer increased survival for patients with locally unresectable pancreatic cancer (Fig. 5).…”