Radiotherapy for Resectable and Borderline Resectable Pancreas Cancer: When and Why?
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REVIEW ARTICLE
Radiotherapy for Resectable and Borderline Resectable Pancreas Cancer: When and Why? Jessica E. Maxwell 1 & Matthew H. G. Katz 1 Received: 15 October 2020 / Accepted: 17 October 2020 # 2020 The Society for Surgery of the Alimentary Tract (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply)
Abstract The role of (chemo) radiation in the perioperative management of patients with resectable and borderline resectable pancreatic ductal adenocarcinoma is controversial. Herein, we review and interpret existing data relating to the ability of (chemo) radiation to “downstage” pancreatic tumors, delay recurrence, and prolong patients’ survival. In sum, the evidence suggests that while neoadjuvant (chemo) radiation may impact pathologic metrics favorably, it rarely converts anatomically unresectable tumors to resectable ones. And while data do support the ability of (chemo)radiation to delay cancer progression, its ability to prolong longevity has not been confirmed. It is possible that (chemo)radiation is effective in prolonging the survival of select patients, but to date, this cohort remains undefined due to heterogeneity in both the populations studied and the regimens used to treat them. Based on our interpretation of existing data, we currently administer neoadjuvant and adjuvant (chemo)radiation selectively to patients with localized pancreatic cancer who we consider at highest risk for local progression. We may also use it as an alternative to pancreatectomy in patients who are poor candidates for surgery. Ultimately, the role of (chemo)radiation in these settings is evolving. Better studies of patients most likely to benefit from its local effects are necessary to clearly define its place within the perioperative treatment algorithms used for patients with localized pancreatic cancer. Keywords Pancreas adenocarcinoma . Radiotherapy . Borderline resectable . Neoadjuvant . Adjuvant Multidisciplinary teams often administer (chemo)radiation therapy (RT) to patients with resectable and borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC) prior to or following pancreatectomy with the aim of prolonging their longevity. Preoperative RT is also frequently requested by surgeons with the objective of “downstaging” BR or locally advanced cancers so as to facilitate or improve the results of subsequent surgery. As we will review herein, however, few compelling high-level data support the ability of RT to consistently downstage pancreatic tumors or to prolong the survival of patients with localized PDAC. In contrast, data do appear to justify the use of RT to reduce local disease recurrence and progression. Thus, surgeons and multidisciplinary teams must thoughtfully and critically integrate RT into the treatment strategy they develop for
* Matthew H. G. Katz [email protected] 1
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1484, Houston, TX 77030-1402, USA
each patient on the basis of
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