Elsevier

Seminars in Oncology

Volume 42, Issue 1, February 2015, Pages 144-162
Seminars in Oncology

The Role of Radiation Therapy in Pancreatic Ductal Adenocarcinoma in the Neoadjuvant and Adjuvant Settings☆

https://doi.org/10.1053/j.seminoncol.2014.12.013Get rights and content

Pancreatic adenocarcinoma (PCA) is associated with high rates of cancer-related morbidity and mortality. Yet despite modern treatment advances, the only curative therapy remains surgical resection. The adjuvant therapeutic standard of care for PCA in the United States includes both chemotherapy and chemoradiation; however, an optimal regimen has not been established. For patients with resectable and borderline resectable PCA, recent investigation has focused efforts on evaluating the feasibility and efficacy of neoadjuvant therapy. Neoadjuvant therapy allows for early initiation of systemic therapy and identification of patients who harbor micrometastatic disease, thus sparing patients the potential morbidities associated with unnecessary radiation or surgery. This article critically reviews the data supporting or refuting the role of radiation therapy in the neoadjuvant and adjuvant settings of PCA management, with a particular focus on determining which patients may be more likely to benefit from radiation therapy.

Section snippets

Staging of Pancreatic Cancer

To understand fully the role of the various treatment modalities used in PCA, one must first understand the common terminology used in staging–specifically, what criteria are used to define resectable, borderline resectable, unresectable (locally advanced), and metastatic disease. For the purposes of this review, we focus primarily on the criteria regarding resectable and borderline resectable PCA.

Resectable Pancreatic Cancer

Based on prospective, randomized data, the latest guidelines presented by the NCCN recommend upfront surgery followed by adjuvant therapy for patients diagnosed with resectable PCA.13 However, single-institution, retrospective and small, prospective phase II studies have reported favorable pathologic results with neoadjuvant therapy.

Advances In Radiation Therapy

Although the standard approach to PCA management includes three-dimensional conformal radiation therapy (3D-CRT) with concurrent gemcitabine or 5-FU, recent advances in technology and RT technique have demonstrated considerable potential in improving patient outcome.

Conclusion And Future Directions

This review provides supporting evidence for the need to better develop two essential aspects of PCA management: staging technique and treatment options. Standardized classification of anatomical resectability, as well as further investigation of imaging and biomarker analysis techniques, are required to improve staging efforts.12 In fact, biomarker validation may be used to predict local versus systemic patterns of failure and to determine tumor sensitivity to chemotherapy and RT.4, 24

The role

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    Conflicts of interest: none.

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