Preoperative chemoradiation for patients with locally advanced adenocarcinoma of the pancreas

Rebekah White, Catherine Lee, Mitchell Anscher, Marsha Gottfried, Robert Wolff, Mary Keogan, Theodore Pappas, Herbert Hurwitz, Douglas Tyler

Research output: Contribution to journalArticle

93 Citations (Scopus)

Abstract

Background: Improved resectability is a major theoretical benefit of preoperative chemoradiation for pancreatic cancer. Since 1994, patients at Duke University Medical Center with locally advanced pancreatic cancer have been treated with multimodality preoperative therapy. The purpose of this study was to review our experience with preoperative therapy for locally advanced pancreatic cancer and determine if an aggressive neoadjuvant regimen would not only downstage these tumors pathologically but also improve the odds of complete surgical resection. Methods: The charts of 25 patients treated with neoadjuvant chemoradiation at Duke University Medical Center with biopsy-proven, locally advanced adenocarcinoma of the pancreas were reviewed. Tumors were defined as locally advanced based on radiographic or intraoperative evidence of disease that abuts the superior mesenteric artery or vein (n = 22) or involves lymph nodes that are within the proposed radiation field (n = 3). All 25 patients received external beam radiotherapy (median dose 4500 cGy) in daily fractions of 180 cGy over 5 weeks. All patients concurrently received 5-fluorouracil (FUJ), and many also received mitomycin C or cisplatin, or both. Patients were given a 3- to 4-week break before a restaging computed tomographic (CT) scan was performed. Three patients were not restaged: one died from metastatic disease; one was reclassified as having a neuroendocrine tumor; and one was lost to follow- up. Results: On restaging after neoadjuvant therapy, 64% of patients had stable or decreased primary tumor size. Radiographically, two patients appeared potentially resectable, and seven others developed evidence of metastatic disease. Eight patients underwent exploration, but only five could he resected. Of the five patients resected, only one had negative margins and negative lymph nodes. This patient had significant pancreatitis on initial exploration. After neoadjuvant therapy, he had a complete response radiographically, and there was no residual cancer in his resection specimen. Pathologic examination of the other resection specimens suggested that despite significant tumor fibrosis, malignant cells persist even at the periphery of the lesions. Conclusion: Although neoadjuvant chemoradiation has many theoretical advantages in managing pancreatic malignancy, true pathologic downstaging of locally advanced lesions into tumors that can be removed with negative nodes and margins appears to be a rare event with currently used therapeutic regimens.

Original languageEnglish (US)
Pages (from-to)38-45
Number of pages8
JournalAnnals of Surgical Oncology
Volume6
Issue number1
DOIs
StatePublished - Jan 1999
Externally publishedYes

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Pancreas
Adenocarcinoma
Pancreatic Neoplasms
Neoplasms
Neoadjuvant Therapy
Lymph Nodes
Mesenteric Veins
Superior Mesenteric Artery
Neuroendocrine Tumors
Lost to Follow-Up
Residual Neoplasm
Mitomycin
Fluorouracil
Pancreatitis
Cisplatin
Fibrosis
Radiotherapy
Therapeutics
Radiation
Biopsy

Keywords

  • Chemoradiation
  • Locally advanced
  • Neoadjuvant
  • Pancreatic cancer

ASJC Scopus subject areas

  • Surgery
  • Oncology

Cite this

Preoperative chemoradiation for patients with locally advanced adenocarcinoma of the pancreas. / White, Rebekah; Lee, Catherine; Anscher, Mitchell; Gottfried, Marsha; Wolff, Robert; Keogan, Mary; Pappas, Theodore; Hurwitz, Herbert; Tyler, Douglas.

In: Annals of Surgical Oncology, Vol. 6, No. 1, 01.1999, p. 38-45.

Research output: Contribution to journalArticle

White, R, Lee, C, Anscher, M, Gottfried, M, Wolff, R, Keogan, M, Pappas, T, Hurwitz, H & Tyler, D 1999, 'Preoperative chemoradiation for patients with locally advanced adenocarcinoma of the pancreas', Annals of Surgical Oncology, vol. 6, no. 1, pp. 38-45. https://doi.org/10.1007/s10434-999-0038-z
White, Rebekah ; Lee, Catherine ; Anscher, Mitchell ; Gottfried, Marsha ; Wolff, Robert ; Keogan, Mary ; Pappas, Theodore ; Hurwitz, Herbert ; Tyler, Douglas. / Preoperative chemoradiation for patients with locally advanced adenocarcinoma of the pancreas. In: Annals of Surgical Oncology. 1999 ; Vol. 6, No. 1. pp. 38-45.
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abstract = "Background: Improved resectability is a major theoretical benefit of preoperative chemoradiation for pancreatic cancer. Since 1994, patients at Duke University Medical Center with locally advanced pancreatic cancer have been treated with multimodality preoperative therapy. The purpose of this study was to review our experience with preoperative therapy for locally advanced pancreatic cancer and determine if an aggressive neoadjuvant regimen would not only downstage these tumors pathologically but also improve the odds of complete surgical resection. Methods: The charts of 25 patients treated with neoadjuvant chemoradiation at Duke University Medical Center with biopsy-proven, locally advanced adenocarcinoma of the pancreas were reviewed. Tumors were defined as locally advanced based on radiographic or intraoperative evidence of disease that abuts the superior mesenteric artery or vein (n = 22) or involves lymph nodes that are within the proposed radiation field (n = 3). All 25 patients received external beam radiotherapy (median dose 4500 cGy) in daily fractions of 180 cGy over 5 weeks. All patients concurrently received 5-fluorouracil (FUJ), and many also received mitomycin C or cisplatin, or both. Patients were given a 3- to 4-week break before a restaging computed tomographic (CT) scan was performed. Three patients were not restaged: one died from metastatic disease; one was reclassified as having a neuroendocrine tumor; and one was lost to follow- up. Results: On restaging after neoadjuvant therapy, 64{\%} of patients had stable or decreased primary tumor size. Radiographically, two patients appeared potentially resectable, and seven others developed evidence of metastatic disease. Eight patients underwent exploration, but only five could he resected. Of the five patients resected, only one had negative margins and negative lymph nodes. This patient had significant pancreatitis on initial exploration. After neoadjuvant therapy, he had a complete response radiographically, and there was no residual cancer in his resection specimen. Pathologic examination of the other resection specimens suggested that despite significant tumor fibrosis, malignant cells persist even at the periphery of the lesions. Conclusion: Although neoadjuvant chemoradiation has many theoretical advantages in managing pancreatic malignancy, true pathologic downstaging of locally advanced lesions into tumors that can be removed with negative nodes and margins appears to be a rare event with currently used therapeutic regimens.",
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AU - Anscher, Mitchell

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AU - Wolff, Robert

AU - Keogan, Mary

AU - Pappas, Theodore

AU - Hurwitz, Herbert

AU - Tyler, Douglas

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N2 - Background: Improved resectability is a major theoretical benefit of preoperative chemoradiation for pancreatic cancer. Since 1994, patients at Duke University Medical Center with locally advanced pancreatic cancer have been treated with multimodality preoperative therapy. The purpose of this study was to review our experience with preoperative therapy for locally advanced pancreatic cancer and determine if an aggressive neoadjuvant regimen would not only downstage these tumors pathologically but also improve the odds of complete surgical resection. Methods: The charts of 25 patients treated with neoadjuvant chemoradiation at Duke University Medical Center with biopsy-proven, locally advanced adenocarcinoma of the pancreas were reviewed. Tumors were defined as locally advanced based on radiographic or intraoperative evidence of disease that abuts the superior mesenteric artery or vein (n = 22) or involves lymph nodes that are within the proposed radiation field (n = 3). All 25 patients received external beam radiotherapy (median dose 4500 cGy) in daily fractions of 180 cGy over 5 weeks. All patients concurrently received 5-fluorouracil (FUJ), and many also received mitomycin C or cisplatin, or both. Patients were given a 3- to 4-week break before a restaging computed tomographic (CT) scan was performed. Three patients were not restaged: one died from metastatic disease; one was reclassified as having a neuroendocrine tumor; and one was lost to follow- up. Results: On restaging after neoadjuvant therapy, 64% of patients had stable or decreased primary tumor size. Radiographically, two patients appeared potentially resectable, and seven others developed evidence of metastatic disease. Eight patients underwent exploration, but only five could he resected. Of the five patients resected, only one had negative margins and negative lymph nodes. This patient had significant pancreatitis on initial exploration. After neoadjuvant therapy, he had a complete response radiographically, and there was no residual cancer in his resection specimen. Pathologic examination of the other resection specimens suggested that despite significant tumor fibrosis, malignant cells persist even at the periphery of the lesions. Conclusion: Although neoadjuvant chemoradiation has many theoretical advantages in managing pancreatic malignancy, true pathologic downstaging of locally advanced lesions into tumors that can be removed with negative nodes and margins appears to be a rare event with currently used therapeutic regimens.

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