J Korean Med Sci.  2015 Jul;30(7):917-923. 10.3346/jkms.2015.30.7.917.

Objective Assessment of Surgical Restaging after Concurrent Chemoradiation for Locally Advanced Pancreatic Cancer

• Paik WH
• Lee SH
• Kim YT
• Park JM
• Song BJ
• Ryu JK

• KMID: 2164477
• DOI: http://doi.org/10.3346/jkms.2015.30.7.917

Abstract

The role of neoadjuvant chemoradiation therapy in locally advanced pancreatic cancer (LAPC) is still controversial. The aim of this study was to evaluate surgical downstaging after concurrent chemoradiation therapy (CCRT) for LAPC by measuring the objective changes after treatment. From January 2003 through July 2011, 54 patients with LAPC underwent neoadjuvant CCRT. Computed tomography findings of the tumor size, including major vessel invasion, were analyzed before and after CCRT. Among the total recruited patients, 14 had borderline resectable malignancy and another 40 were unresectable before CCRT. After CCRT, a partial response was achieved in four patients. Stable disease and further disease progression were achieved in 36 and 14 patients, respectively. Tumor size showed no significant difference before and after CCRT (3.6 +/- 1.1 vs. 3.6 +/- 1.0 cm, P = 0.61). Vessel invasion showed improvement in two patients, while 13 other patients showed further tumor progression. Thirty-nine patients with unresectable malignancy and 11 patients with borderline resectable malignancy at time of initial diagnosis remained unchanged after CCRT. Four patients with borderline pancreatic malignancy progressed to an unresectable stage, whereas one unresectable pancreatic malignancy improved to a borderline resectable stage. Only one patient with borderline resectable disease underwent operation after CCRT; however, curative resection failed due to celiac artery invasion and peritoneal seeding. The adverse events associated with CCRT were tolerable. In conclusion, preoperative CCRT in LAPC rarely leads to surgical downstaging, and it could lower resectability rates.

Keyword

Pancreatic Neoplasms; Neoadjuvant Therapy; Chemotherapy; Radiotherapy; Locally Advanced Pancreatic Cancer

MeSH Terms

Adenocarcinoma/radiography/therapy
Adult
Aged
Aged, 80 and over
Antimetabolites, Antineoplastic/therapeutic use
Antineoplastic Combined Chemotherapy Protocols/therapeutic use
Capecitabine/therapeutic use
Carcinoma, Pancreatic Ductal/*radiography/*therapy
Chemoradiotherapy/adverse effects/*methods
Combined Modality Therapy
Deoxycytidine/analogs & derivatives/therapeutic use
Disease Progression
Female
Fluorouracil/therapeutic use
Humans
Male
Middle Aged
Neoadjuvant Therapy
Neoplasm Staging
Pancreas/blood supply/pathology
Pancreatic Neoplasms/*radiography/*therapy
Retrospective Studies
Treatment Outcome
Antimetabolites, Antineoplastic
Capecitabine
Deoxycytidine
Fluorouracil

Figure

• 

  Fig. 1 Objective measurements of vascular invasion before and after chemoradiotherapy. (A) Computed tomography (CT) images at the level of superior mesenteric artery (SMA). Post-chemoradiotherapy image shows similar vascular involvement with pre-chemoradiotherapy image. (B) CT images at the level of celiac artery (CA) and common hepatic artery (CHA). Post-chemoradiotherapy image shows increased CHA involvement. (C) CT images at the level of CA. Post-chemoraidotherapy image shows decreased CA involvement.

• 

  Fig. 2 Kaplan-Meier curves showing overall survival and progression-free survival of patients. (A) The median overall survival was 16.5 (95% CI 13.2-19.9) months. (B) The median progression-free survival was 6.4 (95% CI 4.0-8.8) months.

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