Chemoradiotherapy in the management of localized tumors of the pancreas

In western countries, carcinoma of the pancreas remains the most lethal of the common malignancies. Even the favorable "organ-confined" tumors present a considerable challenge. The lack of anatomic barriers to local infiltrat ion and the biological propensity for early lymphatic, perineural, and vasc ular invasion are nearly insurmountable obstacles to complete surgical erad ication of this malignancy. Various combinations of chemotherapy and radiot herapy (RT) have been used with marginal but measurable success. Earlier tr ials conducted by the Gastrointestinal Tumor Study Group established roles for 5-fluorouracil chemotherapy and RT in the treatment of patients with re sectable or locally advanced pancreatic cancer. More recently, computed tom ography-guided conformal RT and a variety of intraoperative RT techniques h ave enabled more reliable sterilization of the local surgical field and esc alation of doses to potentially curative levels (7000 cGy) for unresectable lesions. Chemotherapy dose intensification through the use of portable pro grammable pumps for protracted venous infusions and the development of acti ve systemic agents in addition to 5-fluorouracil suggest that an effective combination chemotherapeutic regimen might soon be developed. This report r eviews the current standards of practice and integrates recent developments to construct a modem algorithm for the use of chemoradiotherapy in the man agement of localized (nonmetastatic) pancreatic cancer. The likely directio ns of future investigations are also discussed.