Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma - Anoutcomes trial

BACKGROUND. Resection of pancreatic carcinoma is resource-intensive with a limited impact on survival. Chemotherapy and/or radiotherapy [RT) have been shown to be effective palliation. To examine whether preoperative chemorad iotherapy as the initial treatment improves survival for patients with a re gional pancreatic adenocarcinoma with a minimal chance of being resected su ccessfully, an outcomes trial was conducted. METHODS. Patients with radiologically regional tumors were staged by laparo tomy and/or computed tomography followed by endoscopic ultrasonography, ang iography, and/or laparoscopy. Those with locally invasive, unresectable, re gional pancreatic adenocarcinoma initially were treated with simultaneous s plit-course RT plus 5-fluorouracil, streptozotocin. and cisplatin (RT-FSP) followed by selective surgery (Group 1). Patients determined to have a rese ctable tumor initially underwent resection without preoperative chemoradiot herapy, with or without postoperative chemoradiotherapy (Group 2). RESULTS, Over 8 years 159 patients presenting with nonmetastatic pancreatic adenocarcinoma were administered RT-FSP or underwent surgery for resection . Group 1, comprised of 68 patients initially treated with RT-FSP, had a 0% mortality rate within 30 days of entry. In 20 of 30 patients undergoing su rgery after RT-FSP, tumors were downstaged and resected. Group 2, comprised of 91 patients who initially underwent successful resection, had a 5% mort ality rate within 30 days of entry. Postoperatively, 63 of these patients r eceived chemotherapy with or without RT. The median survival for Group 1 wa s 23.6 months compared with 14.0 months for Group 2 (P = 0.006) despite mor e advanced disease cases in Group 1. Survival favored RT-FSP regardless of whether lymph nodes were malignant. The dominant prognostic factor of earli er stage pancreatic carcinoma having an expected survival advantage was rev ersed by the initial nonoperative treatment. CONCLUSIONS. Based on a reversal of the expected trend that patients with e arlier stage resectable carcinoma (T1,2, N0,1, MO) who undergo removal of t heir tumors survive longer than patients with more advanced regional diseas e (T3, N0,1, MO), survival was found to improve significantly for patients reliably staged as having locally invasive, unresectable, nonmetastatic pan creatic adenocarcinoma when initially treated with RT-FSP. (C) 2000 America n Cancer Society.