Neoadjuvant stereotactic body radiation therapy for nonmetastatic pancreatic adenocarcinoma

Abstract

Background: Neoadjuvant therapy is a strategy for resectable and borderline resectable pancreatic cancer, but a consensus approach regarding optimal management is undetermined. Neoadjuvant options include chemotherapy with/without radiotherapy. Stereotactic body radiation therapy (SBRT) is a novel radiation technique that may provide benefit over conventionally fractionated radiation therapy (CFRT) in the neoadjuvant setting. The purpose of the present study is to determine neoadjuvant treatment with SBRT to other neoadjuvant treatment options for patients with resectable pancreatic cancer. Material and methods: The National Cancer Database was queried (2004-2015) for patients with nonmetastatic pancreatic adenocarcinoma receiving neoadjuvant therapy followed by pancreatectomy. Patients were categorized based on the type of neoadjuvant treatment administered. Statistics included temporal trend assessment by annual percent change (APC), predictors for SBRT by multivariable logistic regression, Kaplan-Meier overall survival (OS) analysis without and with propensity matching, and Cox proportional hazards modeling for univariable OS analysis. Results: Of 5828 patients, 332 (5.7%), 3234 (55.5%) and 2262 (38.8%) received neoadjuvant chemo-SBRT, chemotherapy, and chemo-CFRT, respectively. SBRT utilization increased from 0% in 2004 to 9.5% in 2015, with a greater APC after 2010 (p < .001). SBRT was more likely to be utilized in patients with T3-4 and node-positive disease (p < .05 for all). The chemo-SBRT cohort was associated with a higher OS rate before and after propensity matching (p < .05 for both). The rate of R0 resection was higher in radiotherapy groups than the chemotherapy cohort (p < .001). Conclusions: Utilization of neoadjuvant SBRT for pancreatic cancer is increasing. In the neoadjuvant setting, chemo-SBRT may improve R0 resection and OS over chemotherapy and chemo-CFRT, although confirmatory prospective studies are needed for confirmation.

Novel strategies using modern radiotherapy to improve pancreatic cancer outcomes: toward a new standard?

“…The R0 resection rate was higher in the RT groups than with CT alone ( p < 0.001) and the SBRT group was also associated with better T/N-stage downstaging ( p < 0.001). 141 Substantial expectations were placed upon the randomized phase II Alliance A021501 trial designed to compare the outcomes of BR patients treated with induction with FOLFIRINOX alone or followed by SBRT (33 Gy in 5 fractions with SIB up to 40 Gy at TVI or 25 Gy in 5 fractions). 142 Initially this trial included three arms, but due to the results of the LAP07 trial, the FOLFIRINOX followed by conventional CRT arm was cancelled.…”

Towards an updated view on the clinical management of pancreatic adenocarcinoma: Current and future perspectives (Review)

“…For example, benefits have been found when using stereotactic radiotherapy as adjunctive treatment in high-risk patients with affected margins after surgical resection or with extensive lymphatic invasion ( 124 ). Likewise, the usefulness of radiotherapy as a neoadjuvant treatment has been demonstrated together with the use of chemotherapy in patients with borderline tumors that affect the resection border ( 125 ). Despite being a technique that has reduced the risk of injury to adjacent organs or the presence of pseudoaneurysms, this procedure has been associated with numerous gastrointestinal adverse effects such as nausea, vomiting and diarrhea, although they are usually temporary and are directly related to the radiation therapy sessions ( 126 ).…”

Outcomes of patients with initially locally advanced pancreatic adenocarcinoma who did not benefit from resection: a prospective cohort study

“…In the current study, continued chemotherapy was associated with a higher incidence of adverse events, comparable to the results of a previous series [21] probably because among patients who received CRT, treatment was discontinued until relapse was observed. Fourth, CRT should improve with the development of new techniques such as stereotactic body radiation therapy [22,23] that may provide benefit over conventionally fractionated radiation therapy in the neoadjuvant setting (awaiting the results of the Alliance A021501 trial [24]), and was hence included in the last NCCC version for 2020 considering the treatment for locally advanced pancreatic cancer [25]. Perspectives in patients with non-metastatic LAPA at restaging Physicians must focus on restaging to determine the appropriate treatment for each patient, including CT, liver MRI [26], explorative laparoscopy (with para-aortic lymph node picking if technically feasible), and serum CA 19-9 level measurements.…”