There is a controversy about the use of preoperative therapy in upfront resectable pancreatic cancer. Also some researchers recommend the combination of chemo-radiotherapy.
The radiotherapy of the pancreatic tumors is not recommended, only the chemotherapy in some selected cases
Here is a review: N Am J Med Sci. 2011 Jan; 3(1): 1–12.
Pancreatic cancer: chemotherapy and radiotherapy
Åke Andrén-Sandberg
I quote:
Chemoradiotherapy
"The optimal management for patients with unresectable locally advanced adenocarcinoma of the pancreas (LAPC) is unclear. The aim of this study was to determine the outcome of patients treated with chemoradiotherapy (CRT) with or without induction chemotherapy. It was conducted a multi-centre retrospective analysis of 48 patients with biopsy-proven LAPC treated with CRT in four regional oncology centres in the UK between 2000 and 2007. The prescribed radiotherapy dose was 4500-5040 cGy in 25-28 fractions and was given concurrent with gemcitabine (n=37), gemcitabine/cisplatin (n=9), 5-fluorouracil (n=1) or capecitabine (n=1). Four patients (8.3%) did not complete the intended treatment due to CRT-related toxicities. The disease control rate (Objective response rate (ORR) and stable disease (SD)) was 81 percent. The median overall survival was 17 months (range 5-66 months). In subgroup analysis, a trend towards improved survival was seen in patients who completed the intended treatment (17 months vs. 11 months) and in patients undergoing surgery (27 months vs. 16 months). This is the largest reported series from the UK focusing on patients who received CRT for pancreas cancer. It shows that it is possible to deliver pancreatic CRT with acceptable toxicity. Induction chemotherapy followed by gemcitabine-based CRT shows promising activity and should be evaluated in phase III studie"
i recommend radiotherapy 45GY / 5 weeks concurrent with gemcitabine 600 mg weekly as a neoadjuvant therapy.
we are now in the era of multimodality treatment ..so i recommend neoadjuvant CHT to counteract the incidence of micro metastasis before surgery plus or minus radiotherapy followed by surgery or preserve radiotherapy after surgery as adjuvant ttt for local control and according to pathological prognostic factors after surgery.
There are two basic approach existing in theory to answer that question.
The first one is based on results of clinical trials. Based on them, neoadjuvant treatment of a resectable pancreatic cancer is not recommended, because no phase III data supporting this, regarding both chemo- or chemoradiotherapy.
Some phase II trials had adressed and some ongoing phase III studies investigating the role of neoadjuvant chemotherapy on patients suffering from borderline resectable pancreatic cancer.
On the other hand, we have strong evidences regarding the role of adjuvant chemo. First, gemcitabine monotherapy had been proven to be effective in the CONKO-01 trial at 2007, in terms of improving the disease free and overall survival. Than, in 2016, the results of ESPAC-4 had been presented, and gemcitabine-capecitabine combination showed better overall survival results than gencitabine monotherapy. And now in the last ASCO Annual Meeting (2017) results of mFOLFIRINOX treatment had been introduced and this treatment provided the longest OS results in the treatment of this patient population. So now, this protocol is the reference gold standard adjuvant treatment of resected pancreatic cancer. Not some kind of radiotherapy or chemoradiation, but modified FOLFIRINOX.
The second approach is presuming that the initial staging of pancreatic cancer is often not efficient and there are lots of cases when surgeon finds more advanced disease as it was expected. The followers of this idea like to apply neoadjuvant FOLFIRINOX, because considering the fact that this therapy resulted 31,6% ORR (Conroy 2011),they hope that better surgical outcomes can be achieved. However, there are no phase III trials adressing this issue had been performed till that time.
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