Clinical and Translational Oncology

, Volume 19, Issue 10, pp 1199–1204 | Cite as

Adjuvant treatment for pancreatic ductal carcinoma

  • T. MacarullaEmail author
  • T. Fernández
  • M. E. Gallardo
  • O. Hernando
  • A. M. López
  • M. Hidalgo
Review article


Pancreatic ductal adenocarcinoma (PDAC) is a tumor with a very poor prognosis. Most of the patients are diagnosed in advanced stages of the disease, and 5-year survival rates in these patients remains <10%. Surgery still remains the only radical treatment option, although only 15–20% of patients are candidates for surgical resection at the time of the diagnosis. Patients who undergo radical surgery still have a limited survival rate, being the average of 23 months. Three clinical trials have shown that adjuvant chemotherapy therapy after surgery may improve survival: CONKO-1, ESPAC-3, and ESPAC-4. Adjuvant therapy is recommended in patients with R0/R1, T1-4/N1-0 tumors and with ECOG 0-1. In patients with ECOG-2, the decision needs to be individualized. Treatment schemes that have demonstrated efficacy include gemcitabine alone, 5-fluorouracil, or the combination of gemcitabine and capecitabine for six months. Prior to adjuvant treatment, the following test are recommended: Complete blood tests, including CA19.9 biomarker; imaging studies to rule out early disease relapse (preferable thorax-abdomen-pelvic CT). Studies that have evaluated the efficacy of radiation therapy in the adjuvant setting have presented conflicting results. Its use should be considered in patients with R1 or R2 tumors or in those with lymph nodes involved.


Adjuvant Pancreatic ductal adenocarcinoma Neoadjuvant Surgery Chemotherapy Radiotherapy 



The authors thank Sofía Perea, Pharm D, PhD, for her support in writing the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare to have no conflict of interest.


The support for medical writing was supported by Fundación ECO.

Informed consent


Research involving human participants and/or animals



  1. 1.
  2. 2.
    GLOBOCAN. European age-standardised rates calculated by the statistical information team at cancer research UK, 2011 using data from GLOBOCAN 2008 v1.2, IARC, version 1.2., accesed February 2016
  3. 3.
    Hidalgo M, Cascinu S, Kleeff J, Labianca R, Löhr JM, Neoptolemos J, et al. Addressing the challenges of pancreatic cancer: future directions for improving outcomes. Pancreatology. 2015;15:8–18.CrossRefPubMedGoogle Scholar
  4. 4.
    Dykewicz CA. Summary of the guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. Clin Infect Dis. 2001;33:139–44.CrossRefPubMedGoogle Scholar
  5. 5.
    Oettle H, Neuhaus P, Hochhaus A, Hartmann JT, Gellrt K, Ridwelski K, et al. Adjuvant Chemotherapy With Gemcitabine and Long-term Outcomes Among Patients With Resected Pancreatic Cancer. JAMA. 2013;310:1473–513.CrossRefPubMedGoogle Scholar
  6. 6.
    Neoptolemos JP, Stocken DD, Bassi C, Ghaneh P, Cunningham D, Goldstein D, et al. Adjuvant Chemotherapy With Fluorouracil Plus Folinic Acid vs Gemcitabine Following Pancreatic Cancer Resection. JAMA. 2010;304:1073–112.CrossRefPubMedGoogle Scholar
  7. 7.
    Neoptolemos JP, Palmer D, Ghaneh P, Valle JW, Cunningham D, Wadsley J, et al. Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial. Lancet. 2017;389(10073):1011–24.CrossRefPubMedGoogle Scholar
  8. 8.
    NCCN (National Comprehensive Cancer Network). NCCN clinical practice guidelines in oncology: pancreatic adenocarcinoma, v2.2015.Google Scholar
  9. 9.
    Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, et al. Cancer of the pancreas: ESMO clinical Practice guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 2015;26:v56–68.CrossRefPubMedGoogle Scholar
  10. 10.
    Duelge K, Krepline AN, Mahmoud A (2014) Survival benefit of adjuvant therapy for resectable pancreatic cancer (RPC) patients treated with neoadjuvant Therapy. Oncology 67th annual Cancer Symposium of the Society of Surgical Oncology Phoenix. Annals of Surgical Oncology, Poster P173Google Scholar
  11. 11.
    Cascinu S, Falconi M, Valentini V, Jelic, ESMO Guidelines Working Group. Pancreatic cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 2010;21:v55–8.CrossRefGoogle Scholar
  12. 12.
    Berger AC, Garcia M, Hoffman JP, Regine WF, Abrams RA, Safran H, et al. Postresection CA 19-9 predicts overall survival in patients with pancreatic cancer treated with adjuvant chemoradiation: a prospective validation by RTOG 9704. J Clin Oncol. 2008;26:5918–22.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Yang GY, Malik NK, Chandrasekhar R, Ma WW, Flaherty L, Iyer R, et al. Change in CA 19-9 levels after chemoradiotherapy predicts survival in patients with locally advanced unresectable pancreatic cancer. J Gastrointest Oncol. 2013;4:361–9.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Al-Hawary MM, Francis IR, Chari ST, Fishman EK, Hough DM, Lu DS, et al. Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Radiology. 2014;270:248–60.CrossRefPubMedGoogle Scholar
  15. 15.
    Pietryga JA, Morgan DE. Imaging preoperatively for pancreatic adenocarcinoma. J Gastrointest Oncol. 2015;6:343–57.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Wang XY. Utility of PET/CT in diagnosis, staging, assessment of resectability and metabolic response of pancreatic cancer. WJG. 2014;20:15580–611.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Neoptolemos JP, Stocken DD, Friess H, Bassi C, Dunn JA, Hickey H, et al. A Randomized Trial of Chemoradiotherapy and Chemotherapy after Resection of Pancreatic Cancer. N Engl J Med. 2004;350:1200–10.CrossRefPubMedGoogle Scholar
  18. 18.
    Liao WC, Chien KL, Lin YL, Wu MS, Lin JT, Wang HP, et al. Adjuvant treatments for resected pancreatic adenocarcinoma: a systematic review and network meta-analysis. Lancet Oncol. 2013;14:1095–103.CrossRefPubMedGoogle Scholar
  19. 19.
    Gastrointestinal Tumor Study Group. Further evidence of effective adjuvant combined radiation and chemotherapy following curative resection of pancreatic cancer. Cancer. 1987;59:2006–10.CrossRefGoogle Scholar
  20. 20.
    Klinkenbijil JH, Jeekel J, Sahmoud T. Adjuvant radiotherapy and 5-fluoruracil 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.CrossRefGoogle Scholar
  21. 21.
    Regine WF, Winter KA, Abrams RA. Fluoruracil vs gemcitabine chemotherapy before and after fluoruracil-based chemoradiation following resection of pancreatic adenocarcinoma: a randomized controlled trial. JAMA. 2008;299:1019–26.CrossRefPubMedGoogle Scholar
  22. 22.
    Corsini MM, Miller RC, Haddock MG, Donohue JH. Adjuvant radiotherapy and chemotherapy for pancreatic carcinoma: the Mayo Clinic experience (1975-2005). J Clin Oncol. 2008;26:3511–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Herman JM, Swartz MJ, Hsu CC. Analysis of fluoruracil based adjuvant chemotherapy and radiation after pancreaticoduodenectomy for ductal adenocarcinoma of the pancreas: results of a large prospectively collected database at the Johns Hopkins Hospital. J CLin Oncol. 2008;26:3503–10.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Sinn M, Riess H, Sinn B, Stieler JM, Pelzer U, Striefler JK, et al. Human equillibrative nucleoside transporter 1 expression analysed by the clone SP 120 rabbit antibody is not predictive in patients with pancreatic cancer treated with adjuvant gemcitabine- results from the CONKO-001 trial. Eur J Cancer. 2015;51:1546–54.CrossRefPubMedGoogle Scholar
  25. 25.
    Greenhalf W, Ghaneh P, Neoptolemos J, Palmer DH, Cox TF, Lamb RF, et al (2014) Pancreatic Cancer hENT1 expression and survival from gemcitabine in patients from the ESPAC-3 trial. JNCI 106: djt347Google Scholar
  26. 26.
    Blackford A, Serrano O, Wolfgang C, Parmigiani G, Jones S, Zhang X, et al. SMAD4 gene mutations are associated with poor prognosis in pancreatic cancer. Clin Cancer Res. 2009;158:4674–9.CrossRefGoogle Scholar
  27. 27.
    Witkowski ER, Smith JK, Raqulin-Coyne E, Ng SC, Shah SA, Tseng JF, et al. Is it worth looking? Abdominal imaging after pancreatic cancer resection: a national study. J Gastrointest Surg. 2012;16:121–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Sheffield Kristin M. Surveillance of pancreatic cancer patients after surgical resection. Ann Surg Oncol. 2012;19:1670–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Benavides M, Abad A, Ales I, Carrato A, Díaz Rubio E, Gallego J, et al. TTD consensus document on the diagnosis and management of exocrine pancreatic cancer. Clin Transl Oncol. 2014;16:865–78.CrossRefPubMedGoogle Scholar

Copyright information

© Federación de Sociedades Españolas de Oncología (FESEO) 2017

Authors and Affiliations

  1. 1.Department Medical OncologyHospital Vall d’HebrónBarcelonaSpain
  2. 2.Department Medical OncologyHospital Son LlàtzerPalma De MallorcaSpain
  3. 3.Department Medical OncologyComplejo Hospitalario Universitario de PontevedraPontevedraSpain
  4. 4.Department Radiation OncologyHospital Universitario HM SanchinarroMadridSpain
  5. 5.Department Radiation OncologyHospital Universitario HM Puerta del SurMadridSpain
  6. 6.Department Medical OncologyHospital Universitario de BurgosBurgosSpain
  7. 7.Beth Israel Deaconness Medical CenterHarvard Medical SchoolBostonUSA

Personalised recommendations