Neoadjuvant chemoradiotherapy for adenocarcinoma of the pancreas: Treatment variables and survival duration

Background: For patients with potentially resectable pancreatic cancer, the poor outcome associated with resection alone and the survival advantage de monstrated fur combined-modality therapy have stimulated interest in preope rative chemoradiotherapy. The goal of this study was to analyze the effects of different preoperative chemoradiotherapy schedules, intraoperative radi ation therapy, patient factors, and histopathologic variables on survival d uration and patterns of treatment failure in patients who underwent pancrea ticoduodenectomy for adenocarcinoma of the pancreatic head. Methods: Data on 132 consecutive patients who received preoperative chemora diation followed by pancreaticoduodenectomy fur adenocarcinoma of the pancr eatic head between June 1990 and June 1999 were retrieved from a prospectiv e pancreatic tumor database. Patients received either 45.0 or 50.4 Gy radia tion at 1.8 Gy per fraction in 28 fractions or 30.0 Gy at 3.0 Gy per fracti on in 10 fractions with concomitant infusional chemotherapy (5-fluorouracil , paclitaxel, or gemcitabine). If restaging studies demonstrated no evidenc e of disease progression, patients underwent pancreaticoduodenectomy. All p atients were evaluated with serial postoperative computed tomography scans to document first sites of tumor recurrence. Results: The overall median survival from the time of tissue diagnosis was 21 months (range 19-26, 95%CI). At last follow-up, 41 patients (31%) were a live with no clinical or radiographic evidence of disease. The survival dur ation was superior for women (P = .04) and for patients with no evidence of lymph node metastasis (P = .03). There was no difference in survival durat ion associated with patient age, dose of preoperative radiation therapy, th e delivery of intraoperative radiotherapy, tumor grade, turner size, retrop eritoneal margin status, or the histologic grade of chemoradiation treatmen t effect. Conclusion: This analysis supports prior studies which suggest that the sur vival duration of patients with potentially resectable pancreatic cancer is maximized by the combination of chemoradiation and pancreaticoduodenectomy . Furthermore. there was no difference in survival duration between patient s who received the less toxic rapid-fractionation chemoradiotherapy schedul e (30 Gy, 2 weeks) and those who received standard-fractionation chemoradio therapy (50.4 Gy, 5.5 weeks), short-course rapid-fractionation preoperative chemoradiotherapy combined with pancreaticoduodenectomy, when performed on accurately staged patients, maximizes survival duration and is associated with a low incidence of local tumor recurrence.