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Turner KM, Delman AM, Kharofa JR, Smith MT, Choe KA, Olowokure O, Wilson GC, Patel SH, Sohal D, Ahmad SA. Radiation therapy in borderline resectable pancreatic cancer: A review. Surgery 2022; 172:284-290. [PMID: 35034793 DOI: 10.1016/j.surg.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/11/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Borderline resectable pancreatic cancer constitutes a complex clinical entity, presenting the clinician with a locally aggressive disease that has a proclivity for distant spread. The benefits of radiation therapy, such as improved local control and improved survival, have been questioned. In this review we seek to summarize the existing evidence on radiation therapy in borderline resectable pancreatic cancer and highlight future areas of research. METHODS A comprehensive review of PubMed for clinical studies reporting outcomes in borderline resectable pancreatic cancer was performed in June 2021, with an emphasis placed on prospective studies. RESULTS Radiologic "downstaging" in borderline resectable pancreatic cancer is a rare event, although some evidence shows increased clinical response to neoadjuvant chemotherapy over radiation therapy. Margin status seems to be equivalent between regimens that use neoadjuvant chemotherapy alone and regimens that include neoadjuvant radiation therapy. Local control in borderline resectable pancreatic cancer is likely improved with radiation therapy; however, the benefit of improved local control in a disease marked by systemic failure has been questioned. Although some studies have shown improved survival with radiation therapy, differences in the delivery and tolerance of chemotherapy between the neoadjuvant and adjuvant setting confound these results. When the evidence is evaluated as a whole, there is no clear survival benefit of radiation therapy in borderline resectable pancreatic cancer. CONCLUSION Once considered a staple of therapy, the role of radiation therapy in borderline resectable pancreatic cancer is evolving as systemic therapy regimens continues to improve. Increased clinical understanding of disease phenotype and response are needed to accurately tailor therapy for individual patients and to improve outcomes in this complex patient population.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Jordan R Kharofa
- Department of Radiation Oncology, University of Cincinnati College of Medicine, OH
| | - Milton T Smith
- Division of Digestive Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati College of Medicine, OH
| | - Olugbenga Olowokure
- Division of Hematology & Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH
| | - Davendra Sohal
- Division of Hematology & Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, OH; Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, OH.
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Ahmed AF, Samreen N, Grajo JR, Zendejas I, Sistrom CL, Collinsworth A, Esnakula A, Shah JL, Cabrera R, Geller BS, Toskich BB. Angiosomal radiopathologic analysis of transarterial radioembolization for the treatment of hepatocellular carcinoma. Abdom Radiol (NY) 2018; 43:1825-1836. [PMID: 29052747 DOI: 10.1007/s00261-017-1354-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE To assess the radiopathologic correlation following Yttrium-90 transarterial radioembolization (TARE) of hepatocellular carcinoma (HCC) using variable radiodosimetry to identify imaging surrogates of histologic response. METHODS Twelve patients with HCC underwent ablative (≥ 190 Gy) and/or non-ablative (< 190 Gy) TARE delivered in a segmental, lobar, or combined fashion as a surgical neoadjuvant or bridge to transplantation. Both targeted tumor and treatment angiosome were analyzed before and after TARE utilizing hepatocyte-specific contrast-enhanced MRI or contrast-enhanced CT. Responses were graded using EASL and mRECIST criteria. Histologic findings including percent tumor necrosis and adjacent hepatic substrate effects were correlated with imaging features. RESULTS Complete pathologic necrosis (CPN) was observed in 7/12 tumors post-TARE. Ablative and non-ablative dosing resulted in CPN in 5/6 and 2/6 tumors, respectively. Hyperintensity on T2-weighted imaging, the absence of hepatocyte-specific gadolinium contrast uptake, and plateau or persistent enhancement kinetics in the angiosome correlated with CPN and performed similarly to EASL and mRECIST criteria in predicting CPN. CONCLUSIONS The absence of hepatocyte-specific contrast uptake, increased signal on T2-weighted sequences, and plateau or persistent enhancement in the angiosome may represent MRI surrogates of CPN following TARE of HCC. These findings correlated with EASL and mRECIST response criteria. Further investigation is needed to determine the role of these findings as possible adjuncts to conventional imaging criteria.
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The Role of Radiation Therapy for Pancreatic Cancer in the Adjuvant and Neoadjuvant Settings. Surg Oncol Clin N Am 2017; 26:431-453. [PMID: 28576181 DOI: 10.1016/j.soc.2017.01.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pancreatic cancer is the third leading cause of cancer-related death in the United States. Although surgery remains the only curative treatment, chemotherapy and radiation therapy are frequently used. In the adjuvant setting, radiation is usually delivered with chemotherapy to eradicate residual microscopic or macroscopic disease in the resection bed. Neoadjuvant radiation therapy has become more frequently utilized. This article reviews the historical and modern literature regarding radiation therapy in the neoadjuvant and adjuvant settings, focusing on the evolution of radiation therapy techniques and clinical trials in an attempt to identify patients best suited to receiving radiation therapy.
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Lee KJ, Yoon HI, Chung MJ, Park JY, Bang S, Park SW, Seong JS, Song SY. A Comparison of Gastrointestinal Toxicities between Intensity-Modulated Radiotherapy and Three-Dimensional Conformal Radiotherapy for Pancreatic Cancer. Gut Liver 2016; 10:303-9. [PMID: 26470767 PMCID: PMC4780462 DOI: 10.5009/gnl15186] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Concurrent chemoradiotherapy (CCRT) is considered the treatment option for locally advanced pancreatic cancer, but accompanying gastrointestinal toxicities are the most common complication. With the introduction of three-dimensional conformal radiotherapy (3-D CRT) and intensity-modulated radiotherapy (IMRT), CCRT-related adverse events are expected to diminish. Here, we evaluated the benefits of radiation modalities by comparing gastrointestinal toxicities between 3-D CRT and IMRT. Methods Patients who received CCRT between July 2010 and June 2012 in Severance Hospital, Yonsei University College of Medicine, were enrolled prospectively. The patients underwent upper endoscopy before and 1 month after CCRT. Results A total of 84 patients were enrolled during the study period. The radiotherapy modalities delivered included 3D-CRT (n=40) and IMRT (n=44). The median follow-up period from the start of CCRT was 10.6 months (range, 3.8 to 29.9 months). The symptoms of dyspepsia, nausea/vomiting, and diarrhea did not differ between the groups. Upper endoscopy revealed significantly more gastroduodenal ulcers in the 3-D CRT group (p=0.003). The modality of radiotherapy (3D-CRT; odds ratio [OR], 11.67; p=0.011) and tumor location (body of pancreas; OR, 11.06; p=0.009) were risk factors for gastrointestinal toxicities. Conclusions IMRT is associated with significantly fewer gastroduodenal injuries among patients treated with CCRT for pancreatic cancer.
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Affiliation(s)
- Kyong Joo Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea.,Brain Korea 21 Plus Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sil Seong
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Chuong MD, Boggs DH, Patel KN, Regine WF. Adjuvant chemoradiation for pancreatic cancer: what does the evidence tell us? J Gastrointest Oncol 2014; 5:166-77. [PMID: 24982765 DOI: 10.3978/j.issn.2078-6891.2014.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/08/2014] [Indexed: 12/12/2022] Open
Abstract
The role of adjuvant chemoradiation (CRT) for pancreas cancer remains unclear. A handful of randomized trials conducted decades of ago ignited a debate that continues today about whether CRT improves survival after surgery. The many flaws in these trials are well described in the literature, which include the use of antiquated radiation delivery techniques and suboptimal doses. Recent prospective randomized data is lacking, and we eagerly await the results the ongoing Radiation Therapy Oncology Group (RTOG) 0848 trial that is evaluating the utility of high quality adjuvant CRT in resected pancreas cancer patients. Until the results of RTOG 0848 are available we should look to other studies from the modern era to guide adjuvant treatment recommendations. Here we review the current state of the art for adjuvant pancreas CRT with respect to patient selection, radiation techniques, radiation dose, and integration with novel systemic agents.
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Affiliation(s)
- Michael D Chuong
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - Drexell H Boggs
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - Kruti N Patel
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
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Bockbrader M, Kim E. Role of intensity-modulated radiation therapy in gastrointestinal cancer. Expert Rev Anticancer Ther 2014; 9:637-47. [DOI: 10.1586/era.09.16] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Taylor R, Opfermann K, Jones BD, Terwilliger LE, McDonald DG, Ashenafi MS, Garrett-Meyer E, Marshall DT. Comparison of radiation treatment delivery for pancreatic cancer: Linac intensity-modulated radiotherapy versus helical tomotherapy. J Med Imaging Radiat Oncol 2012; 56:332-7. [PMID: 22697333 DOI: 10.1111/j.1754-9485.2012.02373.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Intensity-modulated radiotherapy (IMRT) has been shown to reduce dose to organs at risk (OAR) while adequately treating tumour volume. This study quantitatively compares the dosimetric differences from step-and-shoot IMRT compared with helical tomotherapy (HT) for pancreatic head cancer. METHODS Twelve consecutive patients with non-metastatic, stage T3 or T4, unresectable pancreatic head cancer were planned for step-and-shoot IMRT as well as HT. Radiotherapy was planned to deliver 45.9 Gy to the clinical target volume in 30 fractions with an integrated boost to 54 Gy to the gross tumour volume (planning target volume 5400 including a 1-cm set-up margin). The uniformity index (UI) and conformity index (CI) were used to compare the quality of target coverage, while the quality index (QI) compared the dosimetric performance for OAR. RESULTS Both methods were effective at covering the tumour with no significant difference in UI or CI. However, HT dosimetry exhibited superior sparing of OAR with significantly less stomach (mean QI(StomV30) = 0.84, P = 0.006) and small bowel dosing (mean small bowel QI(SBV30) = 0.84, P = 0.005). HT reduced dose to the kidney receiving the highest dose but the overall volume of kidney receiving 18 Gy was not significantly different between the two systems, indicating that HT spread the dose more uniformly through the kidneys. CONCLUSIONS Target coverage is equivalent between the two systems; however, HT shows significantly better sparing of the stomach and small bowel. The decreased dose to OAR with HT is likely to improve the therapeutic ratio in the radiotherapy of pancreatic head cancers.
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Affiliation(s)
- Robert Taylor
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina 29464, USA
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Evaluation of dose coverage to target volume and normal tissue sparing in the adjuvant radiotherapy of gastric cancers: 3D-CRT compared with dynamic IMRT. Biomed Imaging Interv J 2010; 6:e29. [PMID: 21611046 PMCID: PMC3097777 DOI: 10.2349/biij.6.3.e29] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 02/20/2010] [Accepted: 04/20/2010] [Indexed: 12/20/2022] Open
Abstract
Purpose: To assess the potential advantage of intensity-modulated radiotherapy (IMRT) over 3D-conformal radiotherapy (3D-CRT) planning in postoperative adjuvant radiotherapy for patients with gastric carcinoma. Methods and materials: In a retrospective study, for plan comparison, dose distribution was recalculated in 15 patients treated with 3D-CRT on the contoured structures of same CT images using an IMRT technique. 3D-conformal plans with three fields and four-fields were compared with seven-field dynamic IMRT plans. The different plans were compared by analyzing the dose coverage of planning target volume using TV95, Dmean, uniformity index, conformity index and homogeneity index parameters. To assess critical organ sparing, Dmean, Dmax, dose to one-third and two-third volumes of the OARs and percentage of volumes receiving more than their tolerance doses were compared. Results: The average dose coverage values of PTV with 3F-CRT and 4F-CRT plans were comparable, where as IMRT plans achieved better target coverage(p<0.001) with higher conformity index value of 0.81±0.07 compared to both the 3D-CRT plans. The doses to the liver and bowel reduced significantly (p<0.001) with IMRT plans compared to other 3D-CRT plans. For all OARs the percentage of volumes receiving more than their tolerance doses were reduced with the IMRT plans. Conclusion: This study showed that a better target coverage and significant dose reduction to OARs could be achieved with the IMRT plans. The IMRT can be preferred with caution for organ motion. The authors are currently studying organ motion in the upper abdomen to use IMRT for patient treatment.
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