Surgical Resection After Preoperative Chemoradiotherapy Benefits Selected Patients With Unresectable Pancreatic Cancer

Abstract

Simultaneous chemoradiation is used in unresectable pancreatic cancer for palliation. It is not known if the use of adjuvant surgery will benefit this group of patients. From November 1991 to September 1998, 47 patients with unresectable pancreatic cancer were treated with simultaneous preoperative radiation therapy (45 Gy) and chemotherapy. Chemotherapy followed three different protocols: cisplatin, 5-fluorouracil +/- paclitaxel; cisplatin, 5-fluorouracil (protracted infusion); and docetaxel and gemcitabine. Whipple pancreatoduodenectomy was performed 1 month after the end of radiation in patients selected for resection. Twenty-three unresectable tumors after preoperative treatment (47%) received an additional dose (10-12 Gy) of radiotherapy using intraoperative or external radiation therapy. Twelve patients (26%) were considered to have clinically resectable tumors after the preoperative treatment. Nine patients had surgery (19% of the total number of patients), and 2 of them had complete pathologic response. After chemoradiation, two patients died of pneumonia and gastrointestinal bleeding, respectively, and another two patients died in the postoperative period. Local recurrence was observed in 22% of the patients and 57% had distant metastases. Three-year survival rates for patients with unresectable and resectable tumors was 0% (median survival 10 months) and 48% (median survival 23 months), respectively (p = 0.0004). Preoperative treatment with chemotherapy and radiotherapy in patients with unresectable pancreatic cancer is feasible. In some patients, the tumor can be resected, and in addition some cases of complete pathologic response were found. Long-term survivors were observed in the group of resected tumors. More effective chemotherapy regimens are needed because the majority of the patients died of metastatic disease.

Combined 90Yttrium‐DOTA‐labeled PAM4 antibody radioimmunotherapy and gemcitabine radiosensitization for the treatment of a human pancreatic cancer xenograft

“…2 Thus, the application of radiosensitizing drugs with concurrent irradiation of the tumor bed, that is, chemoradiation, is being investigated as a primary treatment for locally advanced, unresectable pancreatic cancer, 10 -12,40,41 as well as a neoadjuvant procedure for downstaging of tumor to the point where surgical resection may be feasible. [42][43][44] Although few patients are deemed to have resectable disease, recent studies have suggested that these patients may also benefit from a program of preoperative chemoradiation. [3][4][5][6][7][8][9] Those patients given preoperative chemoradiation had significantly higher numbers of disease-free margins and fewer numbers of involved lymph nodes at surgery than their counterparts treated with "curative resection" alone.…”

Individually optimized stereotactic radiotherapy for pancreatic head tumors: A planning feasibility study

“…22,23 Furthermore, several authors proposed the use of radiotherapy as preoperative treatment. [24][25][26] The reason is that most patients have a locally advanced and, therefore, unresectable tumor at diagnosis. Typically, the reason for unresectability is the infiltration of the blood vessels close to the pancreas (mainly the superior mesenteric artery and vein and the celiac trunk).…”

FOLFIRINOX induction therapy for stage III pancreatic adenocarcinoma

“…It does appear that resectability rates are higher following FOLFIRINOX then they are after non-FOLFIRINOX regimens [6][7][8][9][10][11][12][13] , in which the resectability rates for locally unresectable (stage III) patients treated with induction therapy have ranged between 7%-19%. Small et al 9 reported a multi-institutional phase II study, which assessed the efficacy of gemcitabine with concurrent radiation therapy in nonmetastatic PDAC patients.…”

“…During the pre-FOLFIRINOX era, the conversion rates of stage III patients with induction therapy ranged between 7-19% [6][7][8][9][10][11][12][13] . Currently, the resectability rates after induction FOLFIRINOX for stage III PDAC are not established, as recent series assessing FOLFIRINOX for non-metastatic patients have been either single-arm surgical series with a denominator limited to selected patients who were taken to the operating room, or series composed of a heterogonous population that included both resectable and locally unresectable patients 14 .…”