Adjuvant radiotherapy and chemotherapy for biliary and pancreatic cancer

Intraoperative Radiotherapy for Resectable Pancreatic Cancer Using a Low-Energy X-Ray Source: Postoperative Complications and Early Outcomes

PURPOSE

We evaluated the safety, feasibility, and early treatment outcomes of intraoperative radiotherapy (IORT) using a low-energy X-ray source.

MATERIALS AND METHODS

Patients with resectable pancreatic cancer were enrolled in this single-institution, prospective, single-arm, phase II trial. Patients underwent surgery and IORT with 10 Gy prescribed at a 5-mm depth from the tumor bed using a 50 kV X-ray source (Intrabeam, Carl Zeiss). Six cycles of adjuvant gemcitabine-based chemotherapy were administered 8-12 weeks after surgery.

RESULTS

A total of 41 patients were included. Thirty-one patients (75.6%) underwent wide R0 resection, while 5 (12.2%) underwent R1 resection and 5 (12.2%) underwent narrow R0 resection (retroperitoneal margin <1 mm). Grade 3 postoperative complications were reported in only one patient (4.9%) who needed additional surgery due to ulcer perforation. At a median follow-up of 9 months, four patients showed local-only recurrence, nine had distant metastases, and two showed both local and distant recurrence. The 1-year local control rate was 76.4%.

CONCLUSION

Our preliminary report suggests that IORT is well-tolerated and feasible in patients with resectable pancreatic cancer. Further follow-up is needed to confirm the clinical benefits of IORT in terms of local control and overall survival.

TRIAL REGISTRATION

Trial Registration: Clinical trial registration No. (NCT03273374).

Using the new INTRABEAM mobile intraoperative radiotherapy system during surgery for pancreatic cancer: a case report

Background

Pancreatic cancer is one of the most common fatal malignancies and has a poor prognosis. Surgical treatment is the most important treatment method, but there is a low rate of radical excision; moreover, the postoperative recurrence rate is high, with a local recurrence rate greater than 50%. The usefulness of intraoperative radiotherapy for pancreatic cancer has previously been examined. However, prior research was based on the traditional high-energy electron beam, which causes serious radiation toxicity. Therefore, the tumor radiation dose was limited, subsequently limiting the effect. In contrast, there is also a low-energy X-ray radiation system called INTRABEAM®. Use of INTRABEAM has been applied clinically, but the treatment effect of INTRABEAM in pancreatic cancer has not been reported.

Case presentation

We present a case of a 56-year-old Chinese man with local advanced pancreatic cancer with invasion of the coeliac trunk artery and origin of the portal vein. He underwent distal pancreatectomy and splenectomy along with intraoperative radiotherapy using a portable INTRABEAM radiation system. The radiotherapy dose was 10 Gy and irradiation time was 27.4 minutes. There were no obvious postoperative complications. His abdominal pain was alleviated after surgery, and no obvious tumor recurrence has been observed in short-term follow-up.

Conclusions

We believe that it is safe to apply intraoperative radiotherapy using the INTRABEAM radiation system in pancreatic cancer. This approach appears promising for further future development.

Predictors and patterns of recurrence after curative liver resection in intrahepatic cholangiocarcinoma, for application of postoperative radiotherapy: a retrospective study

Background

The majority of patients with intrahepatic cholangiocarcinoma (IHCC) who undergo complete tumor resection subsequently develop tumor recurrence. The objectives of this study were to determine the risk factors for IHCC recurrence after curative (R0) liver resection and to identify the feasibility about postoperative adjuvant radiation therapy (RT).

Methods

We retrospectively reviewed patients who underwent liver resection for IHCC between April 1995 and December 2012 at Samsung Medical Center. Cox regression analysis was performed to determine risk factors of recurrence. Patients with a recurrence in remnant liver within 2 cm from the resection margin, with or without locoregional lymph node (LN) metastases, were considered as potential RT candidates. Center-of-mass (COM) distances between the recurrent cancers and the cut surface were measured with MATLAB.

Results

We included 153 out of 198 patients who underwent partial liver resection for IHCC. About two thirds (n = 93, 60.8 %) of patients developed recurrent disease. The median recurrence-free survival (RFS) was 14 months (range, 0–204). Tumor size ≥4.0 cm, LN metastasis and multiple tumors were significant predictors of IHCC recurrence on multivariate analysis. Tumor size ≥5.0 cm was the only factor associated with recurrence beyond the RT field in patients with recurrence. Among 93 patients with recurrence, 16 (17.2 %) patients were recurred in the RT field.

Conclusion

After curative resection in IHCC, more than 60 % of patients recurred, and among recurred patients, 17.2 % were recurred within the RT field. Consequently, for control of locoregional recurrence, adjuvant RT could be carefully considered in patients with recurrence factors. Especially, patients with a tumor size larger than 5 cm should be judiciously selected for adjuvant RT.

Early experience of helical tomotherapy for hepatobiliary radiotherapy

Helical tomotherapy (HT), an image-guided, intensity-modulated, radiation therapy technique, allows for precise targeting while sparing normal tissues. We retrospectively assessed the feasibility and tolerance of the hepatobiliary HT in 9 patients. A total dose of 54 to 60 Gy was prescribed (1.8 or 2 Gy per fraction) with concurrent capecitabine for 7 patients. There were 1 hepatocarcinoma, 3 cholangiocarcinoma, 4 liver metastatic patients, and 1 pancreatic adenocarcinoma. All but one patient received previous therapies (chemotherapy, liver radiofrequency, and/or surgery). The median doses delivered to the normal liver and to the right kidney were 15.7 Gy and 4.4 Gy, respectively, below the recommended limits for all patients. Most of the treatment-related adverse events were transient and mild in severity. With a median followup of 12 months, no significant late toxicity was noted. Our results suggested that HT could be safely incorporated into the multidisciplinary treatment of hepatobiliary or pancreatic malignant disease.

Intraoperative radiotherapy for resected pancreatic cancer: a multi-institutional retrospective analysis of 210 patients

PURPOSE

To retrospectively analyze the results of intraoperative radiotherapy (IORT) with or without external beam radiotherapy (EBRT) for resected pancreatic cancer.

METHODS AND MATERIALS

The records of 210 patients treated with gross complete resection (R0: 147 patients; R1: 63 patients) and IORT with or without EBRT were reviewed. One hundred forty-seven patients (70.0%) were treated without EBRT and 114 patients (54.3%) were treated in conjunction with chemotherapy. The median doses of IORT and EBRT were 25 Gy (range, 20-30 Gy) and 45 Gy (range, 20-60Gy), respectively. The median follow-up of the surviving 62 patients was 26.3 months (range, 2.7-90.5 months).

RESULTS

At the time of this analysis, 150 of 210 patients (71.4%) had disease recurrences. Local failure was observed in 31 patients (14.8%), and the 2-year local control rate in all patients was 83.7%. The median survival time and the 2-year actuarial overall survival (OS) in all 210 patients were 19.1 months and 42.1%, respectively. Patients treated with IORT and chemotherapy had a significantly more favorable OS than those treated with IORT alone (p = 0.0011). On univariate analysis, chemotherapy use, degree of resection, carbohydrate antigen 19-9, and pathological N stage had a significant impact on OS and on multivariate analysis; these four factors were significant prognostic factors. Late gastrointestinal morbidity of NCI-CTC Grade 4 was observed in 7 patients (3.3%).

CONCLUSION

IORT yields an excellent local control rate for resected pancreatic cancer with few frequencies of severe late toxicity, and IORT combined with chemotherapy confers a survival benefit compared with that of IORT alone.

Incidence pattern and survival for gallbladder cancer over three decades--an analysis of 10301 patients

BACKGROUND

Little is known about the trends in the incidence, survival, and treatment patterns of gallbladder cancer over the last decade.

METHODS

Data of patients in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute (SEER 13) with a diagnosis of primary gallbladder cancer from 1973-2002 were examined. The effect of surgery and radiotherapy on survival was examined. Incidence of disease, survival, use of surgery, and radiotherapy for patients diagnosed between 1993 and 2002 (Group B) were compared to the others (Group A).

RESULTS

Median age of the 10301 included patients was 73. 72.4% were female and median survival was 4 months. SEER histologic stage was classified as localized (23.7%), regional (37.4%), and distant (38.9%) patients. Median survival for these stages was 20 months, 5 months, and 2 months, respectively. 81.5% patients underwent surgery and 13.3% radiotherapy. Median survival of patients undergoing surgery was significantly longer (8 versus 2 months, P < 0.0001). Radiotherapy in addition to surgery was associated with prolonged survival for patients with regional and distant stages but not localized stage. Over the 3 decades, the incidence of gallbladder cancer gradually decreased in patients older than 50 years, but increased in younger patients. Significantly fewer Group B patients underwent surgery compared with Group A (74.6% versus 89.9%, P < .001). However, the use of radiotherapy was higher in Group B (14.5% versus 12.4%, P < 0.01).

CONCLUSIONS

Over the last decade, the incidence of gallbladder cancer has reduced in patients older than 50 years with an increased incidence in younger patients. Survival of patients has also improved over the last decade. The number of patients undergoing surgery has reduced with an increase in the use of radiotherapy.

Is postoperative adjuvant chemotherapy useful for gallbladder carcinoma? A phase III multicenter prospective randomized controlled trial in patients with resected pancreaticobiliary carcinoma

BACKGROUND

To the authors' knowledge, the significance of postoperative adjuvant chemotherapy in pancreaticobiliary carcinoma has not yet been clarified. A randomized controlled study evaluated the effect of postoperative adjuvant therapy with mitomycin C (MMC) and 5-fluorouracil (5-FU) (MF arm) versus surgery alone (control arm) on survival and disease-free survival (DFS) for each specific disease comprising resected pancreaticobiliary carcinoma (pancreatic, gallbladder, bile duct, or ampulla of Vater carcinoma) separately.

METHODS

Between April 1986 and June 1992, a total of 508 patients with resected pancreatic (n = 173), bile duct (n = 139), gallbladder (n = 140), or ampulla of Vater (n = 56) carcinomas were allocated randomly to either the MF group or the control group. The MF group received MMC (6 mg/m(2) intravenously [i.v.]) at the time of surgery and 5-FU (310 mg/m(2) i.v.) in 2 courses of treatment for 5 consecutive days during postoperative Weeks 1 and 3, followed by 5-FU (100 mg/m(2)orally) daily from postoperative Week 5 until disease recurrence. All patients were followed for 5 years.

RESULTS

After ineligible patients were excluded, 158 patients with pancreatic carcinoma (81 in the MF group and 77 in the control group), 118 patients with bile duct carcinoma (58 in the MF group and 60 in the control group), 112 patients with gallbladder carcinoma (69 in the MF group and 43 in the control group), and 48 patients with carcinoma of the ampulla of Vater (24 in the MF group and 24 in the control group) were evaluated. Good compliance (> 80%) was achieved with MF treatment. The 5-year survival rate in gallbladder carcinoma patients was significantly better in the MF group (26.0%) compared with the control group (14.4%) (P = 0.0367). Similarly, the 5-year DFS rate of patients with gallbladder carcinoma was 20.3% in the MF group, which was significantly higher than the 11.6% DFS rate reported in the control group (P = 0.0210). Significant improvement in body weight compared with the control was observed only in patients with gallbladder carcinoma. There were no apparent differences in 5-year survival and 5-year DFS rates between patients with pancreatic, bile duct, or ampulla of Vater carcinomas. Multivariate analyses demonstrated a tendency for the MF group to have a lower risk of mortality (risk ratio of 0.654; P = 0.0825) and recurrence (risk ratio of 0.626; P = 0.0589). The most commonly reported adverse drug reactions were anorexia, nausea/emesis, stomatitis, and leukopenia, none of which were noted to be serious.

CONCLUSIONS

The results of the current study indicate that gallbladder carcinoma patients who undergo noncurative resections may derive some benefit from systemic chemotherapy. However, alternative modalities must be developed for patients with carcinomas of the pancreas, bile duct, or ampulla of Vater.

Radiotherapy and continuous infusion 5-fluorouracil in patients with nonresectable pancreatic carcinoma

PURPOSE

The current standard local treatment for nonresectable pancreatic carcinoma is radiotherapy (RT) with concurrent 5-fluorouracil (5-FU); however, the optimal schedule for 5-FU administration has not been fully established. In this study, we report on our experience with the combination of RT and continuous infusion 5-FU in a group of patients with locally nonresectable pancreatic carcinoma.

METHODS AND MATERIALS

Forty-two patients with adenocarcinoma of the pancreas were enrolled in a prospective clinical trial. RT was delivered using a four-field technique to a total dose of 59.4 Gy in 33 fractions. 5-FU was given through a central venous catheter at a dose of 300 mg/m(2)/day, 7 d/wk, throughout the entire course of RT.

RESULTS

All patients completed the RT as planned, and 33 (78%) completed the full regimen of chemotherapy. Ten patients (23%) had a partial response, and 32 (77%) had stable disease. Subjective response, defined as the disappearance of symptoms observed at diagnosis, was also evaluated. Two patients (6%) had a complete, and 24 (75%) a partial, remission of symptoms. The median time to progression was 6.2 months, and the median survival time was 9.1 months.

CONCLUSIONS

In terms of local control, the results of our study, with RT and protracted 5-FU infusion, compare well with those of other studies using RT and bolus 5-FU. The control of distant metastatic disease remains an open issue. However, the palliation of symptoms achieved by our treatment schedule in patients with a very poor prognosis and severe symptoms may be regarded as a positive result.

Chemoradiotherapy as preoperative treatment in locally advanced unresectable pancreatic cancer patients: results of a feasibility study

PURPOSE

The combination of radiotherapy and fluorouracil (5-FU) in patients with locally unresectable pancreatic carcinoma has led to a significant increase in survival in comparison with radiotherapy alone. Doxifluridine (5-DFUR) is an orally active fluoropyrimidine, and its cytotoxic metabolite (5-FU) may concentrate in areas of high tumor vascularization. This trial was carried out with the aims of improving locoregional control and making lesions resectable in patients with unresectable pancreatic cancer.

METHODS

5-DFUR was given at a dose of 500 mg/m2 b.i.d. by way of mouth for 4 days every other week for a total of four courses, with leucovorin 25 mg b.i.d. orally being given 2 hours before each 5-DFUR administration. External beam RT was administered at a dose of 1000 cGy per week for 3 weeks, followed by a 2-week break and then by 1000 cGy per week for a further 2 weeks (a total dose of 5000 cGy). The patients were restaged 4 weeks after the end of treatment and explored for resection in cases of partial response (PR).

RESULTS

A total of 32 patients were treated between 1992 and 1997. Ab initio unresectability was shown by laparotomy (16 cases) or computed tomography (16 cases), and was due to vascular invasion in 27 patients, massive regional nodal metastases in nine, and both in four. The median age was 63 years (range 36-71); performance status (PS) (ECOG): 0-1 = 28 and PS 2 = 4. All the patients had measurable disease and were evaluable for response. There were seven PR (22%), 10 SD (31%), and 15 PD (47%). All of the responders underwent surgical exploration, and radical resection was possible in 5. Three of these patients are still disease-free with a follow-up of 18, 27, and 65 months; the other two cases relapsed 11 and 14 months after surgery. The median survival time was 9 months for the entire group, and 1-year survival rate was 31%. The treatment was never stopped because of toxicity. There were no CTC-NCI grade 3 or 4 toxic events; grade 1-2 diarrhea was observed in 10 cases.

CONCLUSIONS

This preoperative regimen was feasible and led to a successful surgical resection in 16% of otherwise inoperable cases. The median survival was comparable with the results obtained after 5-FU infusion plus radiotherapy. The resectability rate, and the benefit in terms of survival in the resected patients, make these results worthy of confirmation by larger studies.

Review article: current treatment and optimal patient management in pancreatic cancer

This review analyses the current state of knowledge and understanding concerning the optimum treatment and therapeutic management of patients who suffer from pancreatic cancer. It outlines recent advances in scientific understanding and assesses their potential future value to clinicians in confronting this disease. Despite a significant expansion in scientific knowledge relating to factors underlying the early development of pancreatic carcinoma, the clinician continues to be restricted to a severely limited therapeutic armoury for this disease. Local therapies (surgery and radiation) are inevitably of limited value in the face of a disease that is normally encountered at a stage where metastasis is already highly developed. Despite such limitations, however, surgery performed in specialist units may be of value for 10-20% of patients, with a 5-year survival rate in such units of between 10 and 24%. This may be improved even further by appropriate use of adjuvant treatment. The advanced stage of the disease when normally encountered emphasizes the potential value of systemic treatment in this therapeutic area. Unfortunately systemic treatment (chemotherapy) has been found to be ineffective to date in significantly extending survival, with a low rate and duration of remission being identified in most trials. The challenge for both the health service and the pharmaceutical industry is to harness recent and future developments in scientific knowledge to the practical benefit of clinicians. Where cure is possible it should be vigorously pursued; where it is not, in this field above all others, clinicians have a duty of care. To achieve this it is necessary to abandon the therapeutic nihilism that has characterized the attitudes of clinicians towards this disease in the past. It is time that such nihilism was replaced by a recognition of the challenges and the opportunities available to clinicians in enhancing the quantity and quality of life available to patients. The dictum of 'curing whenever possible but caring always' should be the future therapeutic philosophy used to guide clinicians in this important and rapidly changing therapeutic area.

External and intraoperative radiotherapy for resectable and unresectable pancreatic cancer: analysis of survival rates and complications

PURPOSE

Clinical results of intraoperative radiotherapy (IORT) and/or external beam radiotherapy (EBRT) for both resectable and unresectable pancreatic cancer were analyzed.

METHODS AND MATERIALS

Between 1980 and 1995, 332 patients with pancreatic cancer were treated with surgery and/or radiation therapy (RT). Of the 332 patients, 157 patients were treated with surgical resection of pancreatic tumor, and the remaining 175 patients had unresectable pancreatic tumors. Among the 157 patients with resected pancreatic cancer, 62 patients were not treated with RT, while 40 patients were treated with EBRT alone (mean RT dose; 46.3 Gy) and 55 patients with IORT (25.2 Gy) +/- EBRT (44.0 Gy). On the other hand, among the 175 patients with unresectable pancreatic cancer, 58 patients were not treated with RT, 46 patients were treated with EBRT alone (39.2 Gy), and the remaining 71 patients with IORT (29.3 Gy) +/- EBRT (41.2 Gy).

RESULTS

For 87 patients with curative resection, the median survival times (MSTs) of the no-RT, the EBRT, and the IORT +/- EBRT groups were 10.4, 13.0, and 15.5 months, respectively, without significant difference. For 70 patients with noncurative resection, the MSTs of the no-RT, the EBRT, and the IORT +/- EBRT groups were 5.3, 8.7, and 6.5 months, respectively. When the EBRT and the IORT +/- EBRT groups were combined, the survival rate was significantly higher than that of the no RT group for noncuratively resected pancreatic cancers (log rank test; p = 0.028). The 2-year survival probability of the IORT +/- EBRT group (16%) was higher than that of the EBRT group (0%). For unresectable pancreatic cancer, the MSTs of 52 patients without distant metastases were 6.7 months for palliative surgery alone, 7.6 months for EBRT alone, and 8.2 months for IORT +/- EBRT. The survival curve of the IORT +/- EBRT group was significantly better than that of the no-RT group (p < 0.05), and the difference between the IORT +/- EBRT and the EBRT alone groups was marginally significant (p = 0.056). In addition, the 2-year survival probability for the IORT +/- EBRT group was 14%, while no 2-year survival was observed in the no RT or the EBRT groups. Multivariate analysis using the Cox proportional hazards model revealed that tumor size, stage (Stages 1, 2 vs. Stages 3, 4), and curability of resection were significant variables for resectable pancreatic cancer, while distant metastases and performance of IORT were significant variables for unresectable pancreatic cancer. The dose of EBRT was a marginally significant factor for both resectable and unresectable tumors (both p = 0.06). In terms of complications, ulcers of gastrointestinal tract were noted in 14% of the 126 patients treated with IORT.

CONCLUSION

Although prolongation of the MST by IORT was not remarkable, long survivals (>2 years) were obtained by IORT +/- EBRT for noncuratively resected and unresectable pancreatic cancer. IORT combined with EBRT is indicated for noncurative resected or unresectable pancreatic cancer without distant metastases.

Systemic and adjuvant therapy for patients with pancreatic carcinoma

BACKGROUND

Pancreatic cancer is a highly lethal disease with < or = 5% of patients surviving 5 years. There is no curative therapy for patients who cannot be surgically resected. Chemotherapy and radiation therapy can provide palliation but have not had a significant impact on 5-year survival.

METHODS

Newer approaches for improving the survival of patients with pancreatic cancer integrating chemotherapy, radiation therapy, and surgery are being evaluated. New chemotherapeutic agents (e.g., gemcitabine, camptothecins, taxanes, thymydilate synthase inhibitors, and fluorouracil-related compounds) are being studied alone and in combination with each other or different agents (e.g., trimetrexate or platinum-related compounds).

RESULTS

Increased knowledge about the biology of pancreatic cancer (including high frequency of ras and p53 mutations in neoplastic cells or the expression of a number of growth factor receptors on the cell surface) has lead to preclinical evaluation of novel approaches attempting to specifically target these. These novel approaches include gene therapy, vaccines, and antisense oligonucleotides targeted to genes important for proliferation or survival of pancreatic cancer cells.

CONCLUSIONS

Continued development of new approaches is needed to improve the treatment and survival of patients with pancreatic cancer.