Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma

Abstract

BACKGROUND Resection of pancreatic carcinoma is resource‐intensive with a limited impact on survival. Chemotherapy and/or radiotherapy (RT) have been shown to be effective palliation. To examine whether preoperative chemoradiotherapy as the initial treatment improves survival for patients with a regional pancreatic adenocarcinoma with a minimal chance of being resected successfully, an outcomes trial was conducted. METHODS Patients with radiologically regional tumors were staged by laparotomy and/or computed tomography followed by endoscopic ultrasonography, angiography, and/or laparoscopy. Those with locally invasive, unresectable, regional pancreatic adenocarcinoma initially were treated with simultaneous split‐course RT plus 5‐fluorouracil, streptozotocin, and cisplatin (RT‐FSP) followed by selective surgery (Group 1). Patients determined to have a resectable tumor initially underwent resection without preoperative chemoradiotherapy, with or without postoperative chemoradiotherapy (Group 2). RESULTS Over 8 years 159 patients presenting with nonmetastatic pancreatic adenocarcinoma were administered RT‐FSP or underwent surgery for resection. Group 1, comprised of 68 patients initially treated with RT‐FSP, had a 0% mortality rate within 30 days of entry. In 20 of 30 patients undergoing surgery after RT‐FSP, tumors were downstaged and resected. Group 2, comprised of 91 patients who initially underwent successful resection, had a 5% mortality rate within 30 days of entry. Postoperatively, 63 of these patients received chemotherapy with or without RT. The median survival for Group 1 was 23.6 months compared with 14.0 months for Group 2 (P = 0.006) despite more advanced disease cases in Group 1. Survival favored RT‐FSP regardless of whether lymph nodes were malignant. The dominant prognostic factor of earlier stage pancreatic carcinoma having an expected survival advantage was reversed by the initial nonoperative treatment. CONCLUSIONS Based on a reversal of the expected trend that patients with earlier stage resectable carcinoma (T1,2, N0,1, M0) who undergo removal of their tumors survive longer than patients with more advanced regional disease (T3, N0,1, M0), survival was found to improve significantly for patients reliably staged as having locally invasive, unresectable, nonmetastatic pancreatic adenocarcinoma when initially treated with RT‐FSP. Cancer 2000;89:314–27. © 2000 American Cancer Society.

Weekly full-dose gemcitabine and single-dose cisplatin with concurrent radiotherapy in patients with locally advanced pancreatic cancer

“…The median survival time of patients with objective response (CR þ PR), SD, and PD were 18.3, 16.7, and 7.5 months, respectively. chemoradiotherapy, potentially allowing the patient to expect long-term survival after curative resection (Snady et al, 2000;Ammori et al, 2003). In a chemoradiotherapeutic setting, the chemotherapeutic agent should be a potent radiosensitiser to maximise the therapeutic gain of radiotherapy on primary tumours and have a systemic cytotoxicity to reduce the early metastasis of pancreatic cancer (Moertel et al, 1981;Blackstock et al, 1999).…”

Neoadjuvant chemoradiation and pancreaticoduodenectomy for initially locally advanced head pancreatic adenocarcinoma

“…We suggest that a neoadjuvant approach should be preferred and should include gemcitabine-based chemotherapy and radiation therapy. This makes sense, particularly since delayed recovery after surgery precludes adjuvant therapy in approximately 30% of patients who undergo elective PD as the initial treatment for pancreatic adenocarcinoma 29,30 . However, the best neoadjuvant regimen is still to be determined 31 .…”

Chemotherapy for pancreatic cancer

“…Snady et al reported a median survival of 23.6 months in 68 patients with locally invasive 'unresectable' pancreatic adenocarcinoma who had preoperative chemoradiotherapy (split-course radiotherapy plus 5-FU, streptozocin and CDDP), whilst 91 other patients who underwent a resection had a median survival of only 14 months. 176 In the latter resection group, 63 patients received post-operative chemotherapy or chemoradiotherapy with a median survival of 16 months compared to 11 months in those who had resection without further treatment. 176 Magnin et al…”

“…176 In the latter resection group, 63 patients received post-operative chemotherapy or chemoradiotherapy with a median survival of 16 months compared to 11 months in those who had resection without further treatment. 176 Magnin et al…”