External and intraoperative radiotherapy for resectable and unresectable pancreatic cancer: analysis of survival rates and complications

The Use of Intraoperative Radiation Therapy (IORT) in Multimodality Management of Cancer Patients: a Single Institution Experience

BACKGROUND

Intraoperative radiation therapy (IORT) is a highly conformal type of radiation therapy given at time of surgery aiming for better tumor local control. It increases the tumor radiation dose without exceeding normal tissues tolerance doses.

PURPOSE

To assess the feasibility of IORT and short-term toxicities in patients with different cancer sites treated with multidisciplinary protocol including IORT.

PATIENTS AND METHODS

Medical records of cancer patients who received IORT as a part of their multidisciplinary treatment at King Faisal Specialized Hospital and Research center (KFSH&RC), Riyadh, Saudi Arabia, from January 2013 until December 2017 were retrospectively reviewed.

RESULTS

A total of 188 patients with 210 IORT applications were analyzed. Twenty-two patients had two applications at the same time. One hundred sixteen patients were males. Median age at time of diagnosis was 49.5 years (19-77). One hundred thirty-four patients had primary, while 54 cases had recurrent disease. Gastroesophageal cancer and soft tissue sarcoma were the most frequent diagnosis in 49 patients followed by colorectal cancer in 35 patients. Major surgeries with curative intent done in 183 patients (97.3%). Hyperthermic intraperitoneal chemotherapy (HIPEC) was performed in 118 (62.8%) patients. The 30-day postoperative mortality rate was 3.2%. Fifty-four (28.7%) patients develop grades III-IV complications according to Clavien-Dindo grading system.

CONCLUSION

The data presented discusses using of IORT treatment for different malignant tumors as a part of multimodality treatment. IORT seems safe and feasible; however, a longer follow-up period is needed for proper evaluation and to define the role of IORT in a tailored multimodality approach.

Intraoperative radiotherapy vs concurrent chemoradiotherapy in the treatment of patients with locally advanced pancreatic cancer

PURPOSE

The purpose of the multi-institutional retrospective study was to evaluate whether intraoperative radiotherapy (IORT) has advantages in the treatment of patients with locally advanced pancreatic cancer (LAPC) compared with concurrent chemoradiotherapy (CCRT).

PATIENTS AND METHODS

A total of 103 patients with LAPC whom was treated with IORT (Arm A; n = 50) or CCRT (Arm B; n = 53) from 2015.6 to 2016.7 were retrospectively identified. Data on feasibility, toxicity, and overall survival (OS) were evaluated.

RESULTS

Most factors of the two cohorts were similar. The severe adverse events (grade 3 and 4) patients in Arm B were higher than patients in Arm A (34% vs 0%). Disease progression was noted in 38 patients (76%) in Arm A and 37 patients (69.8%) in Arm B. The median survival of patients in Arm A and B were 15.3 months (95% CI, 13.0-17.6 months) and 13.8 months (95% CI, 11.0-16.6 months), respectively. The 1-year survival rate were 66.3% in Arm A (95% CI, 52.3%-80.2%) and 60.9% in Arm B (95% CI, 46.4%-75.4%). There was no significant difference in OS between patients treated with IORT and with CCRT (p = 0.458).

CONCLUSION

Our results demonstrated that patients with LAPC treated with IORT showed fewer adverse events, less treatment time, and high feasibility compared to CCRT. Although, IORT has no advantages in survival and tumor control compared with CCRT.

The role of intraoperative radiation therapy in resectable pancreatic cancer: a systematic review and meta-analysis

Purpose

Several studies investigating the role of intraoperative radiotherapy (IORT) in the treatment of resectable pancreatic cancer (PC) have been published; however, their results remain inconsistent. By conducting a systematic review and meta-analysis, this study aimed to compare clinical outcomes in patients with resectable PC who underwent surgery with or without IORT.

Methods and materials

The MEDLINE/PubMed, EMBASE, and Cochrane Library databases were searched to identify relevant studies published up to February 28, 2019. The main outcome measures included median survival time (MST), local recurrence (LR), postoperative complications, and operation-related mortality. Pooled effect estimates were obtained by performing a random-effects meta-analysis.

Results

A total of 1095 studies were screened for inclusion, of which 15 studies with 834 patients were included in the meta-analysis. Overall, 401 patients underwent pancreatic resection with IORT and 433 underwent surgery without IORT. The pooled analysis revealed that IORT group experienced favorable overall survival (median survival rate [MSR], 1.20; 95% confidence interval [CI], 1.06–1.37, P = 0.005), compared with patients who did not receive IORT. Additionally, the pooled data showed a significantly reduced LR rate in the IORT group compared with that in the non-IORT group (relative risk [RR], 0.70; 95% CI, 0.51–0.97, P = 0.03). The incidences of postoperative complications (RR, 0.95; 95% CI, 0.73–1.23) and operation-related mortality (RR, 1.07; 95% CI, 0.44–2.63) were similar between the IORT and non-IORT groups.

Conclusion

IORT significantly improved locoregional control and overall survival in patients with resectable PC, without increasing postoperative complications and operation-related mortality rates.

Hospitalization Burden of Biliary Strictures and Cholangitis After Pancreaticoduodenectomy

BACKGROUND

Postsurgical biliary disease in Roux-en-y and cholecystectomies has been investigated, but less literature exists regarding biliary complications after Whipple procedure (pancreaticoduodenectomy [PD]). Moreover, the hospital burden incurred after this complication has not been previously examined. The aim of this study is to assess the trends in hospitalization for biliary strictures and cholangitis after PD.

MATERIALS AND METHODS

The National Inpatient Sample identified all cases with a PD and a primary diagnosis of biliary complication in 2014. Cases were identified using the International Classification of Diseases, Clinical Modification codes. Primary outcomes were association of biliary complications with mortality, cost of admission, and length of stay.

RESULTS

A total of 10,145 patients in 2014 were documented with a previous PD. Mortality was 50-fold greater without biliary complications (2.7% versus 0.05%), but a 95% increased length of stay (25.8 d versus 13.2 d, P = 0.014) and 70% increased cost of admission ($293,894 versus $165,862, P = 0.092) occurred with biliary complications. Regression analysis revealed increased length of stay in all cohorts (adjusted odds ratio: 14.3, P = 0.007) and increased cost of admission with cholangitis (adjusted odds: 458283, P = 0.00). Finally, there was increased biliary strictures, cost of hospitalization, and length of stay from 2011 to 2014.

CONCLUSIONS

Biliary disease due to the PD appears to longitudinally increase length of stay and cost of hospitalization. Compared with gastrointestinal bleed and delayed gastric emptying, biliary strictures and cholangitis are still very high acuity, requiring more extensive medical resources. Minimally invasive surgeries and robotics could play a vital role in minimizing biliary complications and the ensuing hospitalization burden.

Recent advances in radiation therapy of pancreatic cancer

Pancreatic cancer has a dismal prognosis with an overall survival outcome of just 5% at five years. However, paralleling our improved understanding of the biology of pancreatic cancer, treatment paradigms have also continued to evolve with newer advances in surgical techniques, chemotherapeutic agents, radiation therapy (RT) techniques, and immunotherapy paradigms. RT dose, modality, fraction size, and sequencing are being evaluated actively, and the interplay between RT and immune effects has opened up newer avenues of research. In this review, we will emphasize recent advances in RT for pancreatic cancer, focusing on preoperative chemoradiation, RT dose escalation, sparing of the spleen to reduce lymphopenia, and combination of RT with immunotherapy.

Intraoperative radiotherapy with the Intrabeam® device for the treatment of resectable pancreatic adenocarcinoma

INTRODUCTION

The application of intraoperative radiation therapy to the tumor bed after resection of pancreatic cancer has been shown to be beneficial in the local control of the disease. The objective of this study was to evaluate the preliminary outcomes after the application of a single intraoperative dose to the tumor bed with a new intraoperative radiotherapy device (Intrabeam^®) in terms of viability, safety and short-term results.

METHODS

We studied 5 patients who underwent pancreaticoduodenectomy for resectable pancreatic cancer in which a radiotherapy boost (5Gy) was intraoperatively applied to the tumoral bed using the portable Intrabeam^® device, a low-energy point-source X-ray. Postoperative complications, hospital stay and mortality, recurrences and short-term survival were analyzed.

RESULTS

Mean patient age was 68 years. All patients had a T3-stage tumor and one of them N1. In 3 patients, R0 resection was performed, while R1 resection was conducted in 2. Perioperative mortality was 0%. The only complications included delayed gastric emptying and postoperative hemorrhage. There were no pancreatic fistulas. During follow-up (mean: 11.2 months), there was a relapse in the patient who had undergone R1 resection.

CONCLUSIONS

The application of radiotherapy with the Intrabeam^® device in selected patients has not resulted in increased perioperative morbidity or mortality; therefore, this is a safe procedure for the treatment of resectable cancer.

Value of surgical resection and timing of therapy in patients with pancreatic cancer at high risk for positive margins

Background

Surgical resection remains the best chance at long-term survival in pancreatic cancer, though margin-positive resections are associated with diminished survival. We examined the effect of margin-positive resection on survival, as well as the role and timing of additional therapies through the National Cancer Database (NCDB).

Patients and methods

Patients with stage IIA–III pancreatic adenocarcinoma diagnosed from 2004 to 2013 were identified in NCDB. Survival was compared using univariate and multivariate Cox proportional hazards modelling for patients who underwent surgery with negative (R0), microscopically positive (R1) and macroscopically positive (R2) margins or non-surgical treatment. We further analysed patients by margin status, timing of additional therapy (neoadjuvant therapy (NAT) vs adjuvant therapy (AT) vs none) and clinical stage.

Results

We analysed 44 852 patients. Median survival (MS) for patients who did not undergo surgery was 10.3 months, compared with 19.7 months for R0 (P<0.001), 14.3 months for R1 (P<0.001) and 9.8 months (P=0.07) for R2 resections. NAT (MS 23.2 months) was associated with improved survival compared with AT (MS 21.5 months) in negative-margin patients and equivalent (MS 17.6 months) to AT (MS 16.8 months) in positive-margin patients. Survival for stage III NAT positive-margin patients (MS 19.8 months) was equivalent to AT after negative margins (MS 18.4 months, P=1.00). Improved R0 rates were seen with NAT (88% vs 81%, P<0.001), especially in stage III patients (85% vs 59%, P<0.001).

Conclusion

R1 resections portend poorer survival than R0 but do not negate the benefit of surgery when additional therapy is given. NAT was associated with improved R0 rates and improved survival for stage III positive-margin patients.

Intraoperative radiotherapy: review of techniques and results

Intraoperative radiotherapy (IORT) is a technique that involves precise delivery of a large dose of ionising radiation to the tumour or tumour bed during surgery. Direct visualisation of the tumour bed and ability to space out the normal tissues from the tumour bed allows maximisation of the dose to the tumour while minimising the dose to normal tissues. This results in an improved therapeutic ratio with IORT. Although it was introduced in the 1960s, it has seen a resurgence of popularity with the introduction of self-shielding mobile linear accelerators and low-kV IORT devices, which by eliminating the logistical issues of transport of the patient during surgery for radiotherapy or building a shielded operating room, has enabled its wider use in the community.

Electrons, low-kV X-rays and HDR brachytherapy are all different methods of IORT in current clinical use. Each method has its own unique set of advantages and disadvantages, its own set of indications where one may be better suited than the other, and each requires a specific kind of expertise.

IORT has demonstrated its efficacy in a wide variety of intra-abdominal tumours, recurrent colorectal cancers, recurrent gynaecological cancers, and soft-tissue tumours. Recently, it has emerged as an attractive treatment option for selected, early-stage breast cancer, owing to the ability to complete the entire course of radiotherapy during surgery. IORT has been used in a multitude of roles across these sites, for dose escalation (retroperitoneal sarcoma), EBRT dose de-escalation (paediatric tumours), as sole radiation modality (early breast cancers) and as a re-irradiation modality (recurrent rectal and gynaecological cancers).

This article aims to provide a review of the rationale, techniques, and outcomes for IORT across different sites relevant to current clinical practice.

Intraoperative radiation therapy (IORT) in pancreatic cancer

Despite the important improvements made in the fields of surgery, chemotherapy and radiation therapy, pancreatic cancer remains one of the most lethal malignancies. Improved outcomes with novel chemotherapy regimes led again to increased attention on the role of localized radiotherapy, since local tumor progression causes significant morbidity and mortality in patients. Even after resection local failure rates are as high as 50-80%. The immediate proximity to critical structures (bone marrow, spinal cord, kidneys, liver, and intestine) limits the dose of radiation that can be administered to the tumor bed with conventional external beam radiation therapy (EBRT). The intraoperative radiotherapy (IORT) appears to be an ideal therapeutic strategy for this disease, having the advantage of enabling the delivery of high doses of radiation to areas that are at risk for microscopic disease, saving critical organs and reducing the possibility of inducing radiotoxicity. This technique allows a theoretical increase in the radiation therapeutic index to tumor compared to the adjacent organs at risk (OAR). The aim of this review is to update and comment on IORT in the multidisciplinary management of pancreatic cancer.

A systematic review of the role of periadventitial dissection of the superior mesenteric artery in affecting margin status after pancreatoduodenectomy for pancreatic adenocarcinoma

BACKGROUND

Resectable pancreatic ductal adenocarcinoma continues to carry a poor prognosis. Of the controllable clinical variables known to affect outcome, margin status is paramount. Though the importance of a R0 resection is generally accepted, not all margins are easily managed. The superior mesenteric artery [SMA] in particular is the most challenging to clear. The aim of this study was to systematically review the literature with specific focus on the role of a SMA periadventitial dissection during PD and it's effect on margin status in pancreatic adenocarcinoma.

STUDY DESIGN

The MEDLINE, EMBASE and Cochrane databases were searched for abstracts that addressed the effect of margin status on survival and recurrence following pancreaticoduodenectomy [PD]. Quantitative analysis was performed.

RESULTS

The overall incidence of a R1 resection ranged from 16% to 79%. The margin that was most often positive following PD was the SMA margin, which was positive in 15-45% of resected specimens. Most studies suggested that a positive margin was associated with decreased survival. No consistent definition of R0 resection was observed.

CONCLUSIONS

Margin positivity in resectable pancreatic adenocarcinoma is associated with poor survival. Inability to clear the SMA margin is the most common cause of incomplete resection. More complete and consistently reported data are needed to evaluate the potential effect of periadventitial SMA dissection on margin status, local recurrence, or survival.

Late gastrointestinal tissue effects after hypofractionated radiation therapy of the pancreas

BACKGROUND

To consolidate literature reports of serious late gastrointestinal toxicities after hypofractionated radiation treatment of pancreatic cancer and attempt to derive normal tissue complication probability (NTCP) parameters using the Lyman-Kutcher-Burman model.

METHODS

Published reports of late grade 3 or greater gastrointestinal toxicity after hypofractionated treatment of pancreatic cancer were reviewed. The biologically equivalent dose in 1.8 Gy fractions was calculated using the EQD model. NTCP parameters were calculated using the LKB model assuming 1-5% of the normal tissue volume was exposed to the prescription dose with α/β ratios of 3 or 4.

RESULTS

A total of 16 human studies were examined encompassing a total of 1160 patients. Toxicities consisted of ulcers, hemorrhages, obstructions, strictures, and perforations. Non-hemorrhagic and non-perforated ulcers occurred at a rate of 9.1% and were the most commonly reported toxicity. Derived NTCP parameter ranges were as follows: n = 0.38-0.63, m = 0.48-0.49, and TD50 = 35-95 Gy. Regression analysis showed that among various study characteristics, dose was the only significant predictor of toxicity.

CONCLUSIONS

Published gastrointestinal toxicity reports after hypofractionated radiotherapy for pancreatic cancer were compiled. Median dose was predictive of late grade ≥ 3 gastrointestinal toxicity. Preliminary NTCP parameters were derived for multiple volume constraints.

Intraoperative radiotherapy for unresectable pancreatic cancer: a multi-institutional retrospective analysis of 144 patients

PURPOSE

To retrospectively analyze the results of intraoperative radiotherapy (IORT) + external beam radiotherapy (EBRT) for unresectable pancreatic cancer.

METHODS AND MATERIALS

The records of 144 patients treated with IORT, with or without, EBRT were reviewed. One hundred and thirteen patients (78.5%) were treated with IORT + EBRT and 114 patients (79.2%) were treated in conjunction with chemotherapy. The median doses of IORT and EBRT were 25 Gy and 45 Gy, respectively. The median follow-up of all 144 patients was 9.6 months (range, 0.5-69.7 months).

RESULTS

At the time of this analysis, 131 of 144 patients (91.0%) had disease recurrences. Local progression was observed in 60 patients (41.7%), and the 2-year local control (LC) rate in all patients was 44.6%. Patients treated with IORT, with or without, EBRT had significantly more favorable LC (2-year LC, 50.9%) than those treated with IORT without EBRT (p = 0.0004). The 2-year overall survival (OS) rate and the median survival time in all 144 patients were 14.7% and 10.5 months, respectively. Patients treated with chemotherapy had a significantly favorable OS than those treated without chemotherapy (p < 0.0001). On univariate analysis, chemotherapy use alone had a significant impact on OS and on multivariate analysis; chemotherapy use was a significant prognostic factor. Late gastrointestinal morbidity of National Cancer Institute-Common Terminology Criteria Grade 3 was observed in 2 patients (1.4%).

CONCLUSION

IORT + EBRT yields a relatively favorable LC rate for unresectable pancreatic cancer with low frequency of severe late toxicity, and IORT combined with chemotherapy conferred a survival benefit compared with IORT without chemotherapy.

Intraoperative radiotherapy for resected pancreatic cancer: a multi-institutional retrospective analysis of 210 patients

PURPOSE

To retrospectively analyze the results of intraoperative radiotherapy (IORT) with or without external beam radiotherapy (EBRT) for resected pancreatic cancer.

METHODS AND MATERIALS

The records of 210 patients treated with gross complete resection (R0: 147 patients; R1: 63 patients) and IORT with or without EBRT were reviewed. One hundred forty-seven patients (70.0%) were treated without EBRT and 114 patients (54.3%) were treated in conjunction with chemotherapy. The median doses of IORT and EBRT were 25 Gy (range, 20-30 Gy) and 45 Gy (range, 20-60Gy), respectively. The median follow-up of the surviving 62 patients was 26.3 months (range, 2.7-90.5 months).

RESULTS

At the time of this analysis, 150 of 210 patients (71.4%) had disease recurrences. Local failure was observed in 31 patients (14.8%), and the 2-year local control rate in all patients was 83.7%. The median survival time and the 2-year actuarial overall survival (OS) in all 210 patients were 19.1 months and 42.1%, respectively. Patients treated with IORT and chemotherapy had a significantly more favorable OS than those treated with IORT alone (p = 0.0011). On univariate analysis, chemotherapy use, degree of resection, carbohydrate antigen 19-9, and pathological N stage had a significant impact on OS and on multivariate analysis; these four factors were significant prognostic factors. Late gastrointestinal morbidity of NCI-CTC Grade 4 was observed in 7 patients (3.3%).

CONCLUSION

IORT yields an excellent local control rate for resected pancreatic cancer with few frequencies of severe late toxicity, and IORT combined with chemotherapy confers a survival benefit compared with that of IORT alone.

Chemoradiation in pancreatic adenocarcinoma: a literature review

Adenocarcinoma of the exocrine pancreas has an annual incidence of 7,400 cases in the U.K. In comparison with other common cancers of solid organs, namely, breast, colorectal, and prostate cancer, pancreatic cancer has a high morbidity and mortality. Radical resection is possible in only 15%-20% of patients, and only 3%-4% of all patients presenting with this condition achieve long-term control and cure. Various strategies in the form of neoadjuvant and adjuvant treatment have been employed over the years to improve outcome, with limited success. Systemic chemotherapy remains the gold standard in the metastatic setting in good performance status patients, and adjuvant chemotherapy after resection of localized and locally advanced cancer has been found to improve outcome. The role of radiotherapy, however, remains controversial and is an area that merits further investigation in well-conducted multicenter trials at various stages of the disease in combination with systemic agents and exploiting recent advances in the delivery of radiotherapy. In this article, we review the published literature on the use of chemoradiation as a modality in various stages of pancreatic adenocarcinoma and highlight areas that future trials in this field should target for a way forward in this malignancy.

Redefining resection margin status in pancreatic cancer

Curative resection is crucial to survival in pancreatic cancer; however, despite optimization and standardization of surgical procedures, this is not always achieved. This review highlights that the rates of microscopic margin involvement (R1) vary markedly between studies and, although resection margin status is believed to be a key prognostic factor, the rates of margin involvement and local tumour recurrence or overall survival of pancreatic cancer patients are often incongruent. Recent studies indicate that the discrepancy between margin status and clinical outcome is caused by frequent underreporting of microscopic margin involvement. Lack of standardization of pathological examination, confusing nomenclature and controversy regarding the definition of microscopic margin involvement have resulted in the wide variation of reported R1 rates that precludes meaningful comparison of data and clinicopathological correlation.

Adjuvant therapy for adenocarcinoma of the pancreas: analysis of reported trials and recommendations for future progress

The delivery of postoperative combined modality adjuvant therapy for completely resected pancreatic cancer was initially shown to be beneficial on the basis of a prospective, randomized trial published in 1985. Since then, oncologists have debated whether chemotherapy, chemoradiation, or both is optimal adjuvant therapy after pancreatectomy for ductal adenocarcinoma of the pancreas; no global consensus has emerged. Unfortunately, despite the completion of a number of subsequent randomized trials of adjuvant therapy since 1985, no further improvements in overall survival have materialized. This lack of progress is not simply the result of ineffective systemic therapies, but in part the result of poor trial design and calls for a more disciplined approach to the selection of patients for surgery, pathologic assessment of surgical resection margins, and postoperative (pretreatment) imaging. This is the only way to ensure that patients who receive adjuvant therapy are actually receiving therapy for radiographically occult possible microscopic disease, rather than therapy for incompletely resected locally advanced disease or early postoperative metastases. A critical analysis of completed adjuvant trials will be provided and a framework for the conduct of future trials of adjuvant therapy proposed.

Improving outcomes for operable pancreatic cancer: is access to safer surgery the problem?

Despite advances in the understanding and treatment of pancreatic cancer in the last two decades, there is a persisting nihilistic attitude among clinicians. An alarmingly high rate of under-utilization of surgical management for operable pancreatic cancer was recently reported in the USA, where more than half of patients with stage 1 operable disease and no other contraindications were not offered surgery as therapy, denying this group of patients a 20% chance of long-term survival. These data indicate that a nihilistic attitude among clinicians may be a significant and reversible cause of the persisting high mortality of patients with pancreatic cancer. This article examines the modern management of pancreatic cancer, in particular, the advances in surgical care that have reduced the mortality of pancreatectomy to almost that of colonic resection, and outlines a strategy for improving outcomes for patients with pancreatic cancer now and in the future.

Chemotherapy for pancreatic cancer: from metastatic disease to adjuvant therapy

Pancreatic cancer remains a significant therapeutic challenge in oncology as the 21st century begins. Currently available cytotoxic chemotherapeutic agents provide only a modest survival benefit for patients with advanced disease. Recent efforts to improve survival in the setting of locally advanced and metastatic disease have focused on combinations of cytotoxic agents and the integration of newer molecular agents. To date, these strategies have been somewhat disappointing, prompting some experts to consider changes in clinical trial design with more rigorous patient eligibility criteria. In the adjuvant therapy setting, investigation of newer agents has lagged behind studies in more advanced disease, but recent results suggested some evidence of incremental advance. However, just as in advanced pancreatic cancer, without a more disciplined approach to patient selection for surgical intervention and subsequent adjuvant therapy, progress can be expected to remain very slow. This review will provide a brief summary of the history of chemotherapy in the treatment of pancreatic cancer and focus on its current and future role in adjuvant therapy.

Resection margins and R1 rates in pancreatic cancer--are we there yet?

The prognosis of pancreatic cancer is poor, even for those patients who undergo surgical resection. The rate of local recurrence is high, despite the fact that in most series complete ('R0') resection is reported to be achieved in the majority of patients. The discrepancy between pathological assessment and clinical outcome indicates that microscopic margin involvement (R1) is frequently underreported, and potential causes for this are discussed in this review. Special emphasis is given to the variation that exists between currently used dissection techniques and their impact on the assessment of the resection margins in pancreatoduodenectomy specimens.

Adjuvant therapy for pancreatic cancer

Ductal adenocarcinoma of the pancreas is one of the leading causes of cancer death in the UK, Europe and US, with incidence closely paralleling mortality. Until recently, enthusiasm for treating these patients was limited for a number of reasons: the majority of patients undergoing surgery would relapse early, adjuvant treatment was of unproven value and systemic therapy in advanced disease had only a small chance of a short-term benefit. More recently, however, it has become recognised that specialist surgery can improve results and there is evidence that adjuvant chemotherapy has a significant advantage in terms of 5-year survival. In particular adjuvant systemic 5-fluorouracil with folinic acid can result in 5-year survival of < or = 29% (compared with 11% for controls) and adjuvant gemcitabine can improve disease-free survival to 13.4 months from a median of 6.9 months in controls, but not overall survival. In contrast the role of adjuvant chemoradiation in addition to chemotherapy remains unproven and the survival results appear to be inferior to systemic chemotherapy alone. New agents, such as capecitabine and erlotinib, are emerging with some activity in this dismal disease signalling hope for the future.

Primary advanced unresectable pancreatic cancer

Median as well as overall survival of pancreatic cancer patients in the advanced stage is extremely low despite advances in cancer therapy regarding tumor cell biology, therapy resistance, and diagnosis. In matters of chemoradiation therapy (CRT) in locally advanced pancreatic cancer, favorable positive effect has been reached with different radiotherapy proceedings such as intraoperative radiation therapy with or without external chemo-/radiation therapy or with CRT alone with regard to local tumor pain, local tumor remission, or local control of disease and overall survival. Primary (chemo-) radiation therapy only rarely leads to local remission. Intraoperative radiation therapy (IORT) merely reaches pain palliation in most cases. By administering up-to-date primary CRT, especially with gemcitabine-associated CRT, local remission in up to 50% of patients can be observed. By applying neoadjuvant CRT, better resectability and the reduction of postoperative positive lymph node metastasis has been seen in patients with resectable or possibly resectable pancreatic cancer. With primary CRT, resectability can also be achieved in patients with primary unresectable pancreatic cancer. It has been shown at the evaluation of patients' progression samples--either treated with neoadjuvant or primarily with radiotherapy (with conventional radiation technique)--that the rate of local recurrence or local progression can be reduced in comparison with historical cohorts. By contrast, the rate on distant metastases was not affected. Whereas concurrent CRT leads to favorable local tumor control, this procedure has a minor effect as to the survival in most of the studies. Because metastases occur mostly out of the irradiation field and because of partly advanced local tumor progression, the concept of combined CRT with continuing chemotherapy was developed. Median survival of pancreatic patients in the advanced stage is approx. 3-5 months, with a 12-month survival probability of 10% despite advances in cancer therapy. On the other hand, the 5-year survival probability is 0.4%-3.0%. The causes of such a dismal prognosis can be understood first of all in the commonly late diagnosis, second in the aggressive tumor cell biology with continuing therapy resistance, and finally because an acceptable resection rate can be achieved only in specialized centers. Only 10%-15% of patients can be resected after the diagnosis of pancreatic cancer. Resection is considered a potential curative therapy. However, median survival of these patients amounts to only 13-18 months, with a 5-year survival of 10%-20%. The survival rate did not improve with a radical resection and extended lymphadenectomy. Furthermore, 15%-30% of primary nonmetastatic pancreatic cancer is unresectable due to extended vessel infiltration at time of diagnosis. The prognosis for these patients is very dismal due to lack of specific therapy; moreover, median overall survival is a maximum of 6-8 months.

Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma

OBJECTIVE

To better understand the impact of a microscopically positive margin (R1) on patterns of disease recurrence and survival after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma.

SUMMARY BACKGROUND DATA

A positive resection margin after PD is considered to be a poor prognostic factor, and some have proposed that an R1 margin may be a biologic predictor of more aggressive disease. The natural history of patients treated with contemporary multimodality therapy who underwent a positive margin PD has not been described.

METHODS

We analyzed our experience from 1990 to 2004, which included the prospective use of a standardized system for pathologic analysis of all PD specimens. All patients who underwent PD met objective computed tomographic criteria for resection. Standard pathologic evaluation of the PD specimen included permanent section analysis of the final bile duct, pancreatic, and superior mesenteric artery (SMA) margins. First recurrences (all sites) were defined as local, regional, or distant. Survival and follow-up were calculated from the date of initial histologic diagnosis to the dates of first recurrence or death and last contact, respectively.

RESULTS

PD was performed on 360 consecutive patients with pancreatic adenocarcinoma. Minimum follow-up was 12 months (median, 51.9 months). The resection margins were negative (R0) in 300 patients (83.3%) and positive (R1) in 60 (16.7%); no patients had macroscopically positive (R2) margins. By multivariate analysis (MVA), high mean operative blood loss and large tumor size were independent predictors of an R1 resection. Patients who underwent an R1 resection had a median overall survival of 21.5 months compared with 27.8 months in patients who underwent an R0 resection. After controlling for other variables on MVA, resection status did not independently affect survival. By MVA, only lymph node metastases, major perioperative complications, and blood loss adversely affected survival.

CONCLUSIONS

There was no statistically significant difference in patient survival or recurrence based on R status. However, this series is unique in the incorporation of a standardized surgical technique for the SMA dissection, the prospective use of a reproducible system for pathologic evaluation of resection margins, the absence of R2 resections, and the frequent use of multimodality therapy.

Prognostic implication of para-aortic lymph node metastasis in resectable pancreatic cancer

BACKGROUND

The survival curve of patients who undergo surgical resection of pancreatic cancer displays a steep decline within 1 year and a relatively slow decline thereafter. The patients with a short survival time may have identifiable clinicopathologic factors that lead to rapid relapse.

STUDY DESIGN

We analyzed clinicopathologic factors in 133 patients who underwent margin-negative pancreatoduodenectomy with extended radical lymphadenectomy for invasive ductal carcinoma of the pancreas to detect factors that could be responsible for the short survival.

RESULTS

Tumor size, invasion of the anterior pancreatic capsule, retroperitoneal invasion, portal venous invasion, major arterial invasion, and metastasis to the para-aortic lymph nodes were variables associated with survival time in univariate analysis. Metastasis to the para-aortic lymph nodes was the single independent factor with a significant association with mortality in multivariate analysis. Some 84% of the patients who had positive para-aortic lymph nodes died within 1 year, versus 46% of the patients with negative nodes.

CONCLUSIONS

Although tumors that involve the para-aortic lymph nodes may technically be resectable, the expected postoperative survival time for most patients is less than 1 year. If para-aortic nodal metastasis is detected, alternative treatment strategies should be considered.

Chemoradiotherapy in patients with pancreatic carcinoma: phase-I study with a fixed radiation dose and escalating doses of weekly gemcitabine

AIM

The aim of this phase-I study is to determine the maximum tolerated dose (MTD) of weekly gemcitabine in concurrent combination with a total radiation dose of 54 Gy in patients with pancreatic cancer.

METHODS

In all patients, a total dose of 54 Gy was delivered in 30 fractions of 1.8 Gy/day. Gross tumor volume and regional lymph nodes were included in the irradiated volume with a 1- to 1.5-cm margin. The doses of weekly gemcitabine were escalated from 100 mg/m2 by increments of 50 mg/m2. Dose-limiting toxicity (DLT) was defined as hematologic toxicity, prolonged grade-3 non-hematologic toxicity, and incompletion of the planned treatment.

RESULTS

Twenty-six patients entered the trial. From level 1 (100 mg/m2) to level 4 (250 mg/m2), no patient experienced DLT except for 1 patient at level 1. At level 5 (300 mg/m2), 3 of the 5 patients met the DLT criteria. One patient developed severe pulmonary abscess, and the other 2 patients had hematologic DLT. The overall partial response rate was 29%, and the median survival time was 13.7 months. The first relapse occurred at the in-field primary site in 6 patients and at distant organs in 13 patients.

CONCLUSION

The MTD of weekly gemcitabine was 250 mg/m2 in the present chemoradiotherapy setting. The efficacy of this chemoradiotherapy regimen is currently being evaluated in the phase-II setting.

Survival after attempted surgical resection and intraoperative radiation therapy for pancreatic and periampullary adenocarcinoma

PURPOSE

To evaluate a single institution's experience with intraoperative radiation therapy (IORT) in combination with attempted surgical resection for pancreatic and periampullary adenocarcinoma.

METHODS AND MATERIALS

From May 1986 until June 2001, 77 patients at LDS Hospital underwent attempted surgical resection and IORT for pancreatic or periampullary adenocarcinoma. A potentially curative resection was defined as surgery with negative or microscopic positive margins. No patients had metastatic disease at the time of surgery and IORT. Forty-four patients with tumors located in the pancreas and 9 patients with periampullary tumors underwent potentially curative surgical resection and IORT. Twenty-four patients had pancreatic tumors deemed unresectable and underwent surgical bypass and IORT. Actuarial survival was calculated from the date of IORT until last follow-up or death by use of the Kaplan-Meier method.

RESULTS

Patients undergoing a potentially curative resection and IORT for periampullary adenocarcinoma had a median survival of 167 months and a 56% 5-year actuarial survival, compared with a median survival of 16 months and a 19% 5-year actuarial survival for patients undergoing the same treatment for pancreatic adenocarcinoma (p = 0.03). Patients with unresectable disease who underwent bypass and IORT had a median survival of 11 months and a 0% 3-year survival, significantly worse than patients able to undergo surgical resection and IORT (p = 0.0002). The operative mortality for all patients undergoing potentially curative resection and IORT was 3.7%.

CONCLUSIONS

Intraoperative radiation therapy is well tolerated and does not increase the morbidity or mortality of potentially curative surgical resection for pancreatic or periampullary adenocarcinoma. Patients with periampullary adenocarcinoma have a better prognosis than those with pancreatic adenocarcinoma, and patients with unresectable pancreatic disease fared worse.

Surgery for pancreatic cancer: recent controversies and current practice

Pancreatic duct carcinoma remains a common disease with a poor prognosis. More than 30,000 Americans will die of the disease in 2004, making it the fourth leading cause of cancer death. Despite significant advances in the treatment of many other human tumors, the 5-year survival rate for persons diagnosed with pancreatic cancer has not changed in decades and remains <5%. This is due both to the inherently aggressive biology of the disease and to its late diagnosis in most cases. Surgical resection of localized disease remains the only hope for cure of pancreatic cancer. Over the past 2 decades, significant advances in diagnostic imaging, staging, surgical technique, and perioperative care have led to marked improvement in the surgical management of pancreatic cancer patients. Operative mortality rates for pancreaticoduodenectomy are now <5% at major centers, and the average length of hospital stay has been reduced to <2 weeks. Improvements in patient outcome after pancreatic cancer surgery have made possible, for the first time, the design and conduct of large adjuvant therapy studies in pancreatic cancer. Such clinical trials are critical for improving outcomes for pancreatic cancer patients.

Complications of pancreatic surgery

Pancreatic resection is the only treatment option that can lead to a meaningful prolonged survival in pancreatic cancer and, in some instances, perhaps a potential chance for cure. With the advent of organ and function preserving procedures, its use in the treatment of chronic pancreatitis and other less common benign diseases of the pancreas is increasing. Furthermore, over the past two decades, with technical advances and centralization of care, pancreatic surgery has evolved into a safe procedure with mortality rates of <5%. However, postoperative morbidity rates are still substantial. This article reviews the more common procedure-related complications, their prevention and their treatment.

Phase I Study of Hyperfractionated Radiation Therapy with Protracted 5-Fluorouracil Infusion in Patients with Locally Advanced Pancreatic Cancer

OBJECTIVE

This study investigated the maximum-tolerated dose of hyperfractionated radiation therapy with protracted 5-fluorouracil (5-FU) infusion in patients with locally advanced, unresectable pancreatic cancer.

METHODS

Five cohorts of patients were scheduled to receive escalating doses of hyperfractionated radiation therapy (range, 45.6-64.8 Gy). All patients received two fractions of 1.2 Gy each (separated by 6 h) per day for 5 days a week, and received protracted 5-FU infusion (200 mg/m2/day) during the radiation course. The maximum-tolerated dose was defined as one dose level below the dose at which more than one third of 3-6 patients experienced dose-limiting toxicity.

RESULTS

Twenty-nine patients were enrolled in this study. The most common toxicities were nausea/vomiting and anorexia. Although 1 patient developed bleeding from a gastric ulcer 3 months after the completion of chemoradiotherapy, the maximum-tolerated dose was not reached even at the highest dose level (level 5, 64.8 Gy). The median survival time was 12.2 months and the 1-year survival rate was 55.0%.

CONCLUSION

The toxicity associated with our regimen was tolerable up to dose level 5 (64.8 Gy). We are currently conducting a phase II study of this hyperfractionated radiation therapy with protracted 5-FU infusion at a dose of 64.8 Gy.

Survivin expression is a prognostic marker in pancreatic cancer patients

BACKGROUND

In this study, we assessed survivin expression in pancreatic cancer specimens from patients who underwent either pancreatic resection alone or pancreatic resection plus postoperative radiation therapy (PORT) to evaluate whether survivin expression is predictive of sensitivity to PORT and outcome in pancreatic cancer patients.

METHODS

Fifty-two patients who underwent pancreatic resection for ductal adenocarcinomas were included in this study. Forty-seven pancreatic ductal adenocarcinoma and 5 normal pancreatic tissues were evaluated for survivin expression by immunohistochemistry. Then the relationship between survivin expression and clinicopathologic data were analyzed.

RESULTS

Sixty-eight percent (32/47) of pancreatic cancer tissues were positive for survivin expression; 32% (15/47) were negative. Normal pancreatic exocrine tissues were negative for survivin expression (0/5). Survival of the patients with positive survivin was significantly shorter than those with negative survivin (P = .02). Survivin was an independent variable that correlated with overall survival (P = .01). There was no difference in survival time between patients with and without PORT. Likely, PORT showed no impact on survival time in survivin-positive patients (P = .12) as well as in survivin-negative patients (P = .95).

CONCLUSIONS

The results suggest that survivin expression in pancreatic cancer tissues could be a useful prognostic marker in pancreatic cancer patients.

Desmoplastic reaction influences pancreatic cancer growth behavior

Connective tissue growth factor (CTGF), which is regulated by transforming growth factor-ss (TGFss), has recently been implicated in the pathogenesis of fibrotic diseases and tumor stroma. Inasmuch as generation of desmoplastic tissue is characteristic for pancreatic cancer, it is not known whether it gives pancreatic cancer cells a growth advantage or is a reaction of the body to inhibit cancer cell progression. In the present study we analyzed the expression and localization of CTGF and evaluated whether it influences the prognosis of pancreas cancer. Tissue samples were obtained from 25 individuals (6 women, 19 men) undergoing pancreatic resection for pancreatic cancer. Tissue samples from 13 previously healthy organ donors (5 women, 8 men) served as controls. Expression of CTGF was studied by Northern blot analysis. In situ hybridization and immunohistochemistry localized the respective mRNA moieties and proteins in the tissue samples. Northern blot analysis revealed that pancreatic cancer tissue samples exhibited a 46-fold increase in CTGF mRNA expression ( p < 0.001) over that of normal controls. In vitro studies confirmed that pancreatic stellate cells are the major source of CTGF mRNA expression and revealed a large variance in basal and TGFss-induced CTGF expression in cultured pancreatic cancer cells. This could also be confirmed by in situ hybridization, indicating that CTGF mRNA signals were located principally in fibroblasts, with only weak signals in the cancer cells. High CTGF mRNA levels in the tissue samples correlated with better tumor differentiation ( p < 0.03). In addition, patients whose tumors exhibited high CTGF mRNA levels (> onefold increase above normal controls) lived significantly longer than those whose tumors expressed low CTGF mRNA levels (none to onefold) ( p < 0.04 multivariate analysis). Our present data indicate that CTGF, as a downstream mediator of TGFss, is overexpressed in connective tissue cells and to a lesser extent in pancreatic cancer cells. Because patients with high CTGF mRNA expression levels have a better prognosis, our findings indicate that the desmoplastic reaction provides a growth disadvantage for pancreatic cancer cells.

The role of intraoperative radiotherapy in pancreatic cancer

In single-institution studies, IORT at appropriate doses seems to safely improve local control in patients who have locally advanced pancreatic cancer, compared with historical controls. IORT also has been a component of adjuvant treatment programs that have led to excellent local control in resected patients. When considering the use of IORT, it is essential to have an understanding of the physical characteristics of the electron beam and how it can differ with the use of flat and beveled applicators. Although apparent improvement in local control with the use of IORT seems to have produced some improvement in median survival rates, high rates of distant failure continues to prevent a significant improvement in long-term survival. Because effective local control in patients with unresectable pancreatic cancer is a prerequisite to the development of curative therapies, the development of improved systemic therapies in patients with locally advanced pancreatic cancer will likely make local therapies such as the use of IORT even more important in the future.

Different radiogenic effects on microcirculation in healthy pancreas and in pancreatic carcinoma of the rat

OBJECTIVE

To compare the radiogenic effects on microcirculation in healthy and malignant pancreatic tissue.

SUMMARY BACKGROUND DATA

Vascular injury is an important effect of radiotherapy, which has been suggested for antiangiogenic tumor therapy.

METHODS

An established model of duct-like pancreatic cancer (DSL6A) was used. Investigation was performed in 12 healthy and 24 tumor-bearing Lewis rats. The tumors were locally irradiated with 15 Gy in 12 animals 4 weeks after intraperitoneal inoculation. Additionally, local radiation of the normal pancreas was performed in six healthy animals. Intravital microscopy of tumor and normal pancreatic microcirculation was performed 5 days after radiation. Relevant parameters were erythrocyte velocity and functional vessel density. Tumor apoptosis and the fraction of vital tumor cells were estimated histologically 5 and 12 days after radiation.

RESULTS

Local radiation with 15 Gy caused a pronounced impairment of blood flow and functional capillary density in the normal pancreas 5 days after radiation, while the tumor blood flow was not significantly changed. A significant reduction in the fraction of vital tumor cells and a significant increase in tumor apoptosis were observed 12 days after radiation.

CONCLUSIONS

Local radiation impairs blood flow in healthy pancreas but not in pancreatic cancer tissue. Tumor cell death is the leading consequence of radiation injury in malignant pancreatic tissue without affecting the vascular system of the tumor. The authors conclude that external beam radiation does not appear to be a useful adjunct for a vascular-targeted therapy in pancreatic carcinoma but causes distinct hypoperfusion in the healthy pancreas.

Intraoperative and conformal external-beam radiation therapy with protracted 5-fluorouracil infusion in patients with locally advanced pancreatic carcinoma

BACKGROUND

Chemoradiotherapy is widely used for patients with locally advanced pancreatic carcinoma. The purpose of this study was to clarify the efficacy and feasibility of chemoradiotherapy with more intensive radiotherapy in these patients, using a combination of intraoperative radiotherapy (IORT), conformal external-beam radiaotherapy (EBRT), and protracted 5-fluorouracil (5-FU).

METHODS

Thirty patients with unresectable locally advanced pancreatic carcinoma were enrolled in this Phase II study. The treatment consisted of IORT (25 grays [Gy]), followed by EBRT (40 Gy in 20 fractions, 5 times per week), and concurrent protracted 5-FU infusion (200 mg/m(2)), beginning 2-4 weeks after IORT. The authors evaluated the efficacy and adverse effects of this treatment by following up patients for 12.0-28.1 months. Survival from the date of IORT was calculated using the Kaplan-Meier method.

RESULTS

In 11 of the 30 patients, metastatic spread was detected in the abdominal cavity at laparotomy. The full EBRT dose was administered in 28 of the 30 patients. Of the remaining 2 patients, EBRT was terminated at 8 Gy due to progression of brain metastasis and another patient did not receive EBRT or chemotherapy due to massive ascites after IORT. The overall response rate for primary pancreatic tumor on dynamic computed tomography scan was 23.3% (7 partial responses). Grade 3 or 4 toxicity (according to the National Cancer Institute Common Toxicity Criteria) was observed in 15 of the 28 patients who received the full irradiation dose (53.6%). These included anorexia, nausea, emesis, fatigue, leukopenia, and/or elevation of transaminase levels. There were no directly treatment-related deaths, but 1 patient died of hepatic failure related to late effects of irradiation after 25.6 months. The median survival time of the 30 patients was 7.8 months and the 2-year survival rate was 8.1%. The median survival time of the 19 patients without metastatic spread in the abdominal cavity was 12.9 months and that of the 11 patients with metastatic spread was 5.8 months.

CONCLUSIONS

The present regimen of chemoradiotherapy is not superior to conventional chemoradiotherapy (EBRT and 5-FU) for patients with locally advanced pancreatic carcinoma.

Impact of intraoperative radiation on postoperative and disease-specific outcome after pancreatoduodenectomy for adenocarcinoma: a propensity score analysis

For periampullary cancer,intraoperative radiation therapy (IORT) administered to the site with the highest locoregional recurrence risk carries the rationale to improve tumor control. An IORT effect on survival remains unclear. IORT impact on postoperative outcomes after pancreatectomy for adenocarcinoma was analyzed, with a specific attempt to correct for the nonrandom IORT treatment assignment, and to account for treatment group imbalances in the interpretation of outcome differences. A propensity-score-adjusted analysis, based on variable selection by logistic regression, was used to rebalance treatments. Between 1989 and 1999, 61 patients underwent partial or total pancreatectomy for a primary periampullary adenocarcinoma at the City of Hope National Medical Center. Diagnoses included pancreatic (n = 36), duodenal (n = 11), ampullary (n = 10), and bile duct cancer (n = 4). Thirty patients received IORT to the resection area, with a median dose of 15 Gy (range: 10-20), followed by postoperative external beam radiation (n = 24). Mortality was 0%, the complication rate 61%. Of 33 patients with a documented recurrence, 6 had an isolated locoregional recurrence only (1 IORT versus 5 no IORT, = 0.05); the systemic recurrence pattern differed as well (IORT 94%, no IORT 67%; = 0.04). IORT had no significant impact on hospital stay (overall median: 17 days), disease-free survival (16 months), and overall survival (23 months) when adjusted for those most relevant variables reflecting IORT treatment group assignment propensity. After adjustment for relevant propensity factors, IORT was not linked to a significantly increased risk for complications, hospital stay, or survival hazard. The recurrence pattern may be affected in some patients, but systemic recurrences predominate. We continue to explore IORT in combination with systemic chemotherapy.

Adjuvant radiotherapy in resectable pancreatic carcinoma

AIM

Pancreatic cancer is a near fatal disease. External beam radiotherapy and intraoperative radiation therapy (IORT) has been proposed with the aim to improve clinical outcome in resectable tumors. The aim of this study is to assess the feasibility and outcome in patients with cT1-3 pancreatic cancer, treated with surgery, external beam radiotherapy and IORT.

METHODS

From 1990 to 1996, 17 patients with clinical stage T1-3N0-1M0 adenocarcinoma of the head of the pancreas were treated with pancreatectomy and pre- (nine patients: 5 Gy), intra- (all patients: 10 Gy) and post-operative (all patients: 50 Gy) radiotherapy. The pathologic T stages were: 4 pT2 and 13 pT3. The pathologic N stages were: 9 pN0 and 8 pN1. Minimum follow-up in living patients was 60 months.

RESULTS

No perioperative mortalities were recorded. Two patients showed postoperative morbidity (11.8%) which required a subsequent laparotomy. The disease-free survival at 1, 3 and 5 years was 41, 23 and 18%, respectively (median: 9 months). The overall survival at 1, 3 and 5 years was 70%, 41% and 18%, respectively (median: 17.5 months). Three patients developed local failure (17.6%) and 12 patients showed distant metastases (70.6%). Univariate analysis (logrank) showed: a significant correlation between both N-stage and retroperitoneal involvement (RPI) with local control (N-stage: P=0.0155; RPI:P =0.0295), a significant correlation between maximum tumor size and metastases-free survival (P=0.0167) and overall survival (P=0.0241); the female gender was another predictor of prolonged survival (P= 0.0465). Multivariate analysis (Cox) showed a significant impact of N-stage and retroperitoneal involvement on local control and also a significant correlation between perineural involvement and tumor diameter with metastases-free survival.

CONCLUSIONS

These results are similar to those of other published series and suggest that this approach is feasible with acceptable local control and survival, especially in patients with small tumors (<2.5 cm: 5 year survival=33.3%) and in female patients (5 year survival=30%). Due to the impact of gender, tumor diameter and N stage on prognosis, in the design of future trials a stratification of patients based on these categories should be considered. The search of effective chemotherapeutic agents is required, to reduce the high incidence of distant metastases, especially in larger tumors.

Intraoperative hyperthermia and chemoradiotherapy for inoperable pancreatic carcinoma

The aim of this study was to evaluate the tolerability and the possible clinical benefit of intraoperative hyperthermia combined with multischedule chemotherapy and bypass surgery for the palliative treatment of inoperable pancreatic cancer. Ten patients with unresectable adenocarcinoma of the pancreas received preoperative chemotherapy [5-fluorouracil (5-FU)], bypass surgery and postoperative chemotherapy (5-FU, doxorubicin and cisplatin) plus sandostatin and radiotherapy (45 Gy, 25 fractions, 5 days a week). A single session of intraoperative hyperthermia was performed, by using a waveguide-type applicator (433 MHz). The tumour region was heated to 43-45 degrees C for up to 60 min, while 500 mg 5-FU was infused simultaneously through the gastroduodenal into the splenic artery. Postoperative recovery was uneventful for all patients. A brief instrument was developed for evaluating patients' quality of life. Chemotherapy-related toxicity included myelosuppression, vomiting, alopecia and increase in blood urea nitrogen (BUN), creatinine, SGOT and SGPT. Glucose and amylase determinations remained within normal limits throughout the whole treatment. There was a significant improvement before and 1 month after combined treatment in Eastern Cooperative Oncology Group (ECOG) status (1.8 +/- 0.4), Scott-Huskinsson pain scale (3.2 +/- 0.8) and quality of life score (30.5 +/- 6.7). No progressive disease was noticed and the median overall survival was 11 (SE = 2.4) months. There was also a significant (P = 0.002, Wilcoxon test) decrease in values of both serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19-9), from 7.6 +/- 1.3 ng/mL and 875.7 +/- 104.8 U/mL to 3.5 +/- 0.7 ng/mL and 65.3 +/- 14.1 U/mL respectively. The first clinical results suggest a potential advantage of using combined intraoperative hyperthermia, chemotherapy and postoperative radiotherapy in the palliative treatment of the adenocarcinoma of the pancreas. The whole procedure seems to be free of perioperative morbidity, while the chemotherapy toxicity was rather moderate. However, the preliminary nature limits the general applicability of our results.

Management of locally advanced adenocarcinoma of the pancreas

Pancreatic cancer is one of the deadliest malignancies and is fatal in more than 95% of affected individuals. For locally advanced disease, the combination of 5-FU and radiation appears to offer the best chance for delaying disease progression. The introduction of gemcitabine into chemoradiotherapy regimens may provide additional improvements in the management of patients. Preoperative therapy has proved feasible but has not shown improvement in overall survival.

Vascular-enteric fistulas associated with radiation therapy in patients with pancreatic adenocarcinoma

BACKGROUND

Irradiation therapy is being evaluated widely as an adjunct to therapy of resectable and unresectable pancreatic exocrine carcinoma. Exsanguinating haemorrhage has been an occasional late complication.

CASE OUTLINES

Two patients with unresectable cancer of the pancreas were treated by bypass, chemotherapy and both intra-operative and postoperative irradiation. Both patients died 5-11 months later of gastroduodenal haemorrhage from arterio-enteric fistulas, which were confirmed by autopsy but had been uncontrolled by selective embolisation. A third patient, for whom little other information was available, died of upper abdominal haemorrhage 5 months after a 'curative' resection combined with intra-operative and postoperative irradiation.

DISCUSSION

Judgement in management is difficult because of the poor prognosis from the underlying disease on the one hand versus the fact that site of bleeding has sometimes been from complicating benign disease. Better endovascular techniques of control of such haemorrhage may be developing.

Effect on local control and survival of electron beam intraoperative irradiation for resectable pancreatic adenocarcinoma

PURPOSE

To assess the impact on local control and survival of intraoperative radiotherapy (IORT) in resectable pancreatic adenocarcinoma.

METHODS AND MATERIALS

The outcome of 127 patients surgically treated with curative intent combined with IORT was compared with the therapeutic results of 76 patients treated with surgery as exclusive treatment.

RESULTS

Operative mortality and morbidity were similar in IORT and no-IORT patients. In 49 patients with locally limited disease (Stage I-II; LLD), IORT (n = 30) reduced the local failure rate and significantly prolonged time to local failure (TTLF), time to failure (TTF), and overall survival (OS) with respect to surgery alone (n = 19). The multivariate analyses, stratifying patients by age, tumor grade, resection margins, chemotherapy, and external-beam radiotherapy use, confirmed the independent impact of IORT on outcome. In patients with locally advanced disease (Stage III-IVA; LAD), IORT had an impact on local failure rate and on TTLF when combined with beam energies of greater than 6 MeV, whereas no effect on TTF and OS was observed.

CONCLUSION

IORT did not increase operative mortality and morbidity and achieved a significant improvement in local control and outcome in patients with LLD. In patients with LAD, beam energies greater than 6 MeV prolonged TTLF.

Lack of effectiveness of radiotherapy combined with cisplatin in patients with locally advanced pancreatic carcinoma

BACKGROUND

Cisplatin has been reported to enhance the cell-killing effect of radiation. The current study was conducted to evaluate the efficacy and toxicity of radiotherapy combined with cisplatin in patients with locally advanced pancreatic carcinoma.

METHODS

Forty-one patients with pancreatic carcinoma that was unresectable but confined to the pancreatic region were treated with external beam radiation (50.4 grays [Gy] in 28 fractions over 5.5 weeks) and daily cisplatin (5 mg/m(2)/day as a 30-minute infusion just before each radiation fraction). Maintenance 5-fluorouracil (5-FU) (500 mg/m(2)) given once weekly was initiated 1 week after the completion of the chemoradiotherapy and continued until disease progression or unacceptable toxicity.

RESULTS

Of the 41 patients, 31 (76%) completed the scheduled course of chemoradiotherapy. The median survival time was 7.7 months, and the 1-year survival rate was 36%. The median progression free survival time was 5.8 months. The first site of failure was distant metastases in 25 patients, locoregional recurrence in 6 patients, and both sites in 1 patient. The major toxicity was leukocytopenia and nausea/emesis.

CONCLUSIONS

Radiotherapy with daily cisplatin appears to be inferior to conventional chemoradiotherapy using 5-FU in patients with locally advanced pancreatic carcinoma.

Prognostic factors in patients with locally advanced pancreatic carcinoma receiving chemoradiotherapy

BACKGROUND

The combination of radiation therapy and chemotherapy (chemoradiotherapy [CRT]) has been accepted as standard therapy for patients with locally advanced pancreatic carcinoma (PC). This study investigated prognostic factors in patients with locally advanced PC receiving CRT.

METHODS

Fifty-five consecutive patients with locally advanced PC, who received concurrent radiotherapy (50.4 grays) and chemotherapy using 5-fluorouracil or cisplatin, were analyzed retrospectively to investigate prognostic factors.

RESULTS

Median survival time and overall survival rates at 1 and 2 years were 301 days, 35.1% and 2.4%, respectively. By multivariate analysis using the Cox proportional hazards model, performance status of 0-1 (P < 0.01), absence of regional lymph node swelling (P < 0.01), and serum CA 19-9 level of less than 1000 (P = 0.02) were independent favorable prognostic factors. A prognostic index based on the coefficients of those prognostic factors was used to classify patients into three groups with good, intermediate, and poor prognoses. The median survival times for these three groups were 410, 239, and 143 days, respectively (P < 0.01).

CONCLUSIONS

The results may be helpful in predicting life expectancy, determining treatment strategies, and designing future clinical trials.

Feasibility and efficacy of high dose conformal radiotherapy for patients with locally advanced pancreatic carcinoma

BACKGROUND

The feasibility and efficacy of high dose conformal radiotherapy were examined in the treatment of patients with locally advanced, unresectable pancreatic carcinoma.

METHODS

Forty-four patients with pathologically confirmed, unresectable pancreatic adenocarcinoma without distant metastases were treated in a Phase II study. The patients received three-dimensional, planned, high dose conformal radiotherapy (70-72 grays). Toxicity was scored according to the World Health Organization criteria. Follow-up time ranged from 7 months to 25 months (median, 9 months).

RESULTS

The treatment was feasible. Forty-one patients received the intended total dose. Treatment was never stopped because of toxicity. Acute toxicity was mainly Grade 1 and Grade 2 (in 70% and 57% of patients, respectively), whereas Grade 3 toxicity was seen in 9% of patients. One fatal event occurred that was not treatment related. Late Grade 3 and Grade 4 gastrointestinal toxicity was seen in 3 patients and 2 patients, respectively. Late (Grade 5) gastrointestinal bleeding was observed in 3 patients, 2 of whom had local tumor progression. At 3 months, reduction in tumor size was seen in 27% of patients, stable disease was seen in 20% of patients, and local disease progression was seen in 40% of patients. Ultimately, local disease progression was observed in 44% of patients. No true partial or complete responses were documented. The median survival from the time of diagnosis was 11 months (10 months from the start of radiotherapy). Seventeen of 25 patients (68%) experienced pain relief.

CONCLUSIONS

High dose conformal radiotherapy for the treatment of patients with locally advanced pancreatic carcinoma is feasible with acceptable toxicity. In case of pain, it can offer palliation. The efficacy of the treatment in terms of prolongation of life is not proven. Distant metastases remain the major problem.

Analysis of the clinical benefit of intraoperative radiotherapy in patients undergoing macroscopically curative resection for pancreatic cancer

PURPOSE

To determine the survival of pancreatic cancer patients treated with intraoperative radiotherapy (IORT) and/or external beam radiation therapy (EBRT) following macroscopically curative resection.

METHODS AND MATERIALS

One hundred and thirty-eight patients with pancreatic cancer who had undergone potentially curative total or regional pancreatectomy between 1980 and 1997 were retrospectively analyzed. Among the 138 patients, 98 had a pathologically negative surgical margin and the remaining 40 patients had a positive surgical margin. The usual EBRT dose was 45-55 Gy with a daily fraction of 1.5-2.0 Gy. The median IORT dose was 25 Gy in a single fraction.

RESULTS

The 2-year cause-specific survival rate of patients with pathologically negative surgical margins was 19%, and that of patients with positive margins was 4% (p < 0.005). Although the median survival time (MST) of patients with negative margins treated with IORT and EBRT was significantly longer than that of those treated with operation alone (17 vs. 11 months), no significant difference in survival curves was observed. In patients with positive surgical margins in peripancreatic soft tissue, the difference between the survival curve of patients treated with surgery alone and that of those treated with surgery and radiation therapy was borderline significant (p < 0.10). Patients receiving intraarterial or intraportal infusion chemotherapy had significantly improved survival rates compared with those who did not receive it (p < 0.05).

CONCLUSION

Although the MST was longer in patients with negative margins receiving IORT and EBRT than in those receiving no radiation, improved long-term survival by IORT and/or EBRT was not suggested. In patients with positive margins, our results obtained by IORT/EBRT were encouraging. Randomized studies with much higher patient numbers are necessary to define the role of IORT in curatively resected pancreatic cancer.

New directions in systemic therapy of pancreatic cancer

BACKGROUND

The aggressiveness of pancreatic adenocarcinoma makes it a deadly disease, with its incidence rate and fatality rate almost equal. Surgery represents the only means to provide cure to patients with pancreatic cancer, though the 5-year survival is less than 10%.

METHODS

We review the data on surgical and systemic therapies and provide more details on a newer biologically based medical approach.

RESULTS

Neoadjuvant chemotherapy protocols are confined to one or two institutions, and adjuvant chemotherapy and chemoradiation therapy protocols are far from being standardized. Chemoradiation therapy for locally advanced pancreatic cancer offers limited benefits. Protocols that include gemcitabine and 5-fluorouracil, while comparing favorably to historical controls, offer median survivals at approximately 8 months.

CONCLUSIONS

More effective protocols with combinations of approaches agents are needed to improve the treatment of pancreatic cancer.