Skip to main content
SpringerLink
Log in

Neoadjuvant and Adjuvant Radiotherapy in Operable Pancreatic Cancer

  • Chapter
  • First Online:
Textbook of Pancreatic Cancer

  • 2621 Accesses

Abstract

Pancreatic cancer is a therapeutic challenge in oncology. Even in patients with localized, resectable or borderline resectable disease, the prognosis remains poor. There is increasing evidence to support the use of neoadjuvant concurrent chemoradiation or stereotactic body radiotherapy in resectable and borderline resectable pancreatic cancer in attempt to downstage, improve resectability, optimize local control, and increase the chance of R0/N0 resection. Adjuvant concurrent chemoradiation is controversial due to conflicting reports in the literature. The advances in radiotherapy techniques and image guidance, the use of more efficacious chemotherapy, and the emergence of targeted therapy/immunotherapy over the past decade all pave the way for more therapeutic opportunities to improve the clinical outcome of pancreatic cancer.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Heinrich S, et al. Prospective phase II trial of neoadjuvant chemotherapy with gemcitabine and cisplatin for resectable adenocarcinoma of the pancreatic head. J Clin Oncol. 2008;26:2526–31.

    Article  CAS  PubMed  Google Scholar 

  2. https://www.nccn.org/professionals/physician_gls/default.aspx

  3. Al-Hawary MM, et al. Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the society of abdominal radiology and the American pancreatic association. Gastroenterology. 2014;146:291–304.e1.

    Article  PubMed  Google Scholar 

  4. Stessin AM, et al. Neoadjuvant radiation is associated with improved survival in patients with resectable pancreatic cancer: an analysis of data from the surveillance, epidemiology, and end results (SEER) registry. Int J Radiat Oncol Biol Phys. 2008;72:1128–33.

    Article  PubMed  Google Scholar 

  5. Versteijne E, et al. Meta-analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer. Br J Surg. 2018;105:946–58.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Gillen S, et al. Preoperative/neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of response and resection percentages. PLoS Med. 2010;7:e1000267.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Laurence JM, et al. A systematic review and meta-analysis of survival and surgical outcomes following neoadjuvant chemoradiotherapy for pancreatic cancer. J Gastrointest Surg. 2011;15:2059–69.

    Article  PubMed  Google Scholar 

  8. Jang J-Y, et al. Oncological benefits of neoadjuvant chemoradiation with gemcitabine versus upfront surgery in patients with borderline resectable pancreatic cancer: a prospective, randomized, open-label, multicenter phase 2/3 trial. Ann Surg. 2018;268:215–22.

    Article  PubMed  Google Scholar 

  9. ICRU. Report 50: prescribing, recording, and reporting photon beam therapy. Washington, DC: International Commission on Radiation Units and Measurements; 1993.

    Google Scholar 

  10. ICRU. Report 62: prescribing, recording, and reporting photon beam therapy. Washington, DC: International Commission on Radiation Units and Measurements; 1999.

    Google Scholar 

  11. Versteijne E, et al. Preoperative radiochemotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer (PREOPANC trial): study protocol for a multicentre randomized controlled trial. Trials. 2016;17:127.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Versteijne E, et al. Preoperative chemoradiotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer: results of the Dutch randomized phase III PREOPANC trial. J Clin Oncol. 2020; https://doi.org/10.1200/JCO.19.02274.

  13. Ishikawa O, et al. Concomitant benefit of preoperative irradiation in preventing pancreas fistula formation after pancreatoduodenectomy. Arch Surg. 1991;126:885–9.

    Article  CAS  PubMed  Google Scholar 

  14. Takahashi H, et al. Preoperative chemoradiation reduces the risk of pancreatic fistula after distal pancreatectomy for pancreatic adenocarcinoma. Surgery. 2011;150:547–56.

    Article  PubMed  Google Scholar 

  15. Cooper AB, et al. Does the use of neoadjuvant therapy for pancreatic adenocarcinoma increase postoperative morbidity and mortality rates? J Gastrointest Surg. 2015;19:80–6; discussion 86–7

    Article  PubMed  Google Scholar 

  16. Denbo JW, et al. Preoperative chemoradiation for pancreatic adenocarcinoma does not increase 90-day postoperative morbidity or mortality. J Gastrointest Surg. 2016;20:1975–85.

    Article  PubMed  Google Scholar 

  17. Tachezy M, et al. Sequential neoadjuvant chemoradiotherapy (CRT) followed by curative surgery vs. primary surgery alone for resectable, non-metastasized pancreatic adenocarcinoma: NEOPA-a randomized multicenter phase III study (NCT01900327, DRKS00003893, ISRCTN82191749). BMC Cancer. 2014;14:411.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Palta M, et al. Radiation therapy for pancreatic cancer: executive summary of an ASTRO clinical practice guideline. Pract Radiat Oncol. 2019;9:322–32.

    Article  PubMed  Google Scholar 

  19. Cloyd JM, et al. Impact of hypofractionated and standard fractionated chemoradiation before pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Cancer. 2016;122:2671–9.

    Article  CAS  PubMed  Google Scholar 

  20. Evans DB, et al. Preoperative gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head. J Clin Oncol. 2008;26:3496–502.

    Article  CAS  PubMed  Google Scholar 

  21. Golcher H, et al. Neoadjuvant chemoradiation therapy with gemcitabine/cisplatin and surgery versus immediate surgery in resectable pancreatic cancer: results of the first prospective randomized phase II trial. Strahlenther Onkol. 2015;191:7–16.

    Article  PubMed  Google Scholar 

  22. Murphy JE, et al. Total neoadjuvant therapy with FOLFIRINOX followed by individualized chemoradiotherapy for borderline resectable pancreatic adenocarcinoma: a phase 2 clinical trial. JAMA Oncol. 2018;4:963–9.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Benedict SH, et al. Stereotactic body radiation therapy: the report of AAPM Task Group 101. Med Phys. 2010;37:4078–101.

    Article  PubMed  Google Scholar 

  24. Mellon EA, et al. Long-term outcomes of induction chemotherapy and neoadjuvant stereotactic body radiotherapy for borderline resectable and locally advanced pancreatic adenocarcinoma. Acta Oncol. 2015;54:979–85.

    Article  CAS  PubMed  Google Scholar 

  25. Mellon EA, et al. Favorable perioperative outcomes after resection of borderline resectable pancreatic cancer treated with neoadjuvant stereotactic radiation and chemotherapy compared with upfront pancreatectomy for resectable cancer. J Gastrointest Oncol. 2016;7:547–55.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Katz MHG, et al. Alliance for clinical trials in oncology (ALLIANCE) trial A021501: preoperative extended chemotherapy vs. chemotherapy plus hypofractionated radiation therapy for borderline resectable adenocarcinoma of the head of the pancreas. BMC Cancer. 2017;17:505.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Rosati LM, et al. Integration of stereotactic body radiation therapy into the multidisciplinary management of pancreatic cancer. Semin Radiat Oncol. 2017;27:256–67.

    Article  PubMed  Google Scholar 

  28. Chuong MD, et al. Adjuvant chemoradiation for pancreatic cancer: what does the evidence tell us? Gastrointest Oncol. 2014;5:166–77.

    Google Scholar 

  29. Kalser MH, et al. Pancreatic cancer. Assessment of prognosis by clinical presentation. Cancer. 1985;56:397–402.

    Article  CAS  PubMed  Google Scholar 

  30. Klinkenbijl JH, et al. Adjuvant radiotherapy and 5-fluorouracil after curative resection of cancer of the pancreas and periampullary region: phase III trial of the EORTC gastrointestinal tract cancer cooperative group. Ann Surg. 1999;230:776–82; discussion 782–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Smeenk HG, et al. Long-term survival and metastatic pattern of pancreatic and periampullary cancer after adjuvant chemoradiation or observation: long-term results of EORTC trial 40891. Ann Surg. 2007;246:734–40.

    Article  PubMed  Google Scholar 

  32. Neoptolemos JP, et al. Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial. Lancet. 2001;358:1576–85.

    Article  CAS  PubMed  Google Scholar 

  33. Neoptolemos JP, et al. A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med. 2004;350:1200–10.

    Article  CAS  PubMed  Google Scholar 

  34. Stocken DD, et al. Meta-analysis of randomised adjuvant therapy trials for pancreatic cancer. Br J Cancer. 2005;92:1372–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Regine WF, et al. Fluorouracil vs gemcitabine chemotherapy before and after fluorouracil-based chemoradiation following resection of pancreatic adenocarcinoma: a randomized controlled trial. JAMA. 2008;299:1019–26.

    Article  CAS  PubMed  Google Scholar 

  36. Regine WF, et al. Fluorouracil-based chemoradiation with either gemcitabine or fluorouracil chemotherapy after resection of pancreatic adenocarcinoma: 5-year analysis of the U.S. Intergroup/RTOG 9704 phase III trial. Ann Surg Oncol. 2011;18:1319–26.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Abrams RA, et al. Failure to adhere to protocol specified radiation therapy guidelines was associated with decreased survival in RTOG 9704—a phase III trial of adjuvant chemotherapy and chemoradiotherapy for patients with resected adenocarcinoma of the pancreas. Int J Radiat Oncol Biol Phys. 2012;82:809–16.

    Article  CAS  PubMed  Google Scholar 

  38. Berger AC, et al. Five year results of US intergroup/RTOG 9704 with postoperative CA 19-9 ≤90 U/mL and comparison to the CONKO-001 trial. Int J Radiat Oncol Biol Phys. 2012;84:e291–7.

    Article  PubMed  Google Scholar 

  39. Morganti AG, et al. Multi-institutional pooled analysis on adjuvant chemoradiation in pancreatic cancer. Int J Radiat Oncol Biol Phys. 2014;90:911–7.

    Article  PubMed  Google Scholar 

  40. Van Laethem J-L, et al. Adjuvant gemcitabine alone versus gemcitabine-based chemoradiotherapy after curative resection for pancreatic cancer: a randomized EORTC-40013-22012/FFCD-9203/GERCOR phase II study. J Clin Oncol. 2010;28:4450–6.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Hsu CC, et al. Adjuvant chemoradiation for pancreatic adenocarcinoma: the Johns Hopkins Hospital-Mayo Clinic collaborative study. Ann Surg Oncol. 2010;17:981–90.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Rwigema JC, et al. Adjuvant stereotactic body radiotherapy for resected pancreatic adenocarcinoma with close of positive margins. J Gastrointest Cancer. 2012;43:70–6.

    Article  PubMed  Google Scholar 

  43. Goodman KA, et al. Radiation Therapy Oncology Group consensus panel guidelines for the delineation of the clinical target volume in the postoperative treatment of pancreatic head cancer. Int J Radiat Oncol Biol Phys. 2012;83:901–8.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Hall WA, et al. The transformation of radiation oncology using real-time magnetic resonance guidance: a review. Eur J Cancer. 2019;122:42–52.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Grassberger C, et al. Assessing the interactions between radiotherapy and antitumour immunity. Nat Rev Clin Oncol. 2019;16:729–45.

    Article  PubMed  Google Scholar 

  46. Wild AT, et al. The association between chemoradiation-related lymphopenia and clinical outcomes in patients with locally advanced pancreatic adenocarcinoma. Am J Clin Oncol. 2015;38:259–65.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Wild AT, et al. Lymphocyte-sparing effect of stereotactic body radiation therapy in patients with unresectable pancreatic cancer. Int J Radiat Oncol Biol Phys. 2016;94:571–9.

    Article  PubMed  Google Scholar 

  48. Ellsworth SG. Field size effects on the risk and severity of treatment-induced lymphopenia in patients undergoing radiation therapy for solid tumors. Adv Radiat Oncol. 2018;3:512–9.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Demaria S, et al. The optimal partnership of radiation and immunotherapy: from preclinical studies to clinical translation. Radiat Res. 2014;182:170–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Demaria S, et al. Ionizing radiation inhibition of distant untreated tumors (abscopal effect) is immune mediated. Int J Radiat Oncol Biol Phys. 2004;58:862–70.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Sylvia S. W. Ng & Albert C. Koong

  2. Department of Surgery, Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada

    Natalie G. Coburn

Authors
  1. Sylvia S. W. Ng
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Albert C. Koong
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Natalie G. Coburn
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Natalie G. Coburn .

Editor information

Editors and Affiliations

  1. Stavanger University Hospital, The University of Bergen, Bergen, Norway

    Kjetil Søreide

  2. Chirurgie (VTT), Innsbruck Medical University, Innsbruck, Tirol, Austria

    Stefan Stättner

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Ng, S.S.W., Koong, A.C., Coburn, N.G. (2021). Neoadjuvant and Adjuvant Radiotherapy in Operable Pancreatic Cancer. In: Søreide, K., Stättner, S. (eds) Textbook of Pancreatic Cancer. Springer, Cham. https://doi.org/10.1007/978-3-030-53786-9_46

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-53786-9_46

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-53785-2

  • Online ISBN: 978-3-030-53786-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation