Upfront Chemotherapy Followed by Stereotactic Body Radiation Therapy with or without Surgery in Older Patients with Localized Pancreatic Cancer: A Single Institution Experience and Review of the Literature

Abstract

Objective: To report on clinical outcomes and toxicity in older (age ≥ 70 years) patients with localized pancreatic cancer treated with upfront chemotherapy followed by stereotactic body radiation therapy (SBRT) with or without surgery. Methods: Endpoints included overall survival (OS), local progression-free survival (LPFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and toxicity. Results: A total of 57 older patients were included in the study. Median OS was 19.6 months, with six-month, one-year, and two-year OS rates of 83.4, 66.5, and 42.4%. On MVA, resection status (HR: 0.30, 95% CI 0.12–0.91, p = 0.031) was associated with OS. Patients with surgically resected tumors had improved median OS (29.1 vs. 7.0 months, p < 0.001). On MVA, resection status (HR: 0.40, 95% CI 0.17–0.93, p = 0.034) was also associated with PFS. Patients with surgically resected tumors had improved median PFS (12.9 vs. 1.6 months, p < 0.001). There were 3/57 cases (5.3%) of late grade 3 radiation toxicity and 2/38 cases (5.3%) of Clavien-Dindo grade 3b toxicity in those who underwent resection. Conclusion: Multimodality therapy involving SBRT is safe and feasible in older patients with localized pancreatic cancer. Surgical resection was associated with improved clinical outcomes. As such, older patients who complete chemotherapy should not be excluded from aggressive local therapy when possible.

Multi-Institutional Outcomes of Patients Aged 75 years and Older With Pancreatic Ductal Adenocarcinoma Treated With 5-Fraction Ablative Stereotactic Magnetic Resonance Image-Guided Adaptive Radiation Therapy (A-SMART)

“…20 Our early efficacy results compare favorably with prior studies that evaluated pancreatic SBRT in an elderly patient population (Table 5). 28,29,[41][42][43] There appears to be a significant improvement in LRC and OS with A-SMART over other historical cohorts for unresected patients. Specifically, A-SMART compares favorably to the Reddy et al unresected cohort, which delivered a non-ablative SBRT (BED 10 = 54.8 Gy).…”

“…19,[44][45][46] Neoadjuvant chemotherapy was given to most patients in our study (86%), which is expected to have influenced clinical outcomes when compared to other studies with lower rates of chemotherapy administration (Table 5). 43 However, most patients within our study received a gemcitabine-based chemotherapy regimen that is often used in elderly patients due to increased toxicity concerns of the more potent FOLFIRINOX regimen. These toxicity data suggest that A-SMART does not appear to be more toxic than other standard radiotherapy regimens routinely used for unresectable PDAC; thus, A-SMART should be considered a safe treatment option for these vulnerable patients with limited options.…”