Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
Int J Radiat Oncol Biol Phys. 2012 Jul 1;83(3):916-20. doi: 10.1016/j.ijrobp.2011.08.026. Epub 2012 Jan 25.
Intensity-modulated radiotherapy (IMRT) is increasingly incorporated into therapy for pancreatic cancer. A concern regarding this technique is the potential for geographic miss and decreased local control. We analyzed patterns of first failure among patients treated with IMRT for resected pancreatic cancer.
Seventy-one patients who underwent resection and adjuvant chemoradiation for pancreas cancer are included in this report. IMRT was used for all to a median dose of 50.4 Gy. Concurrent chemotherapy was 5-FU-based in 72% of patients and gemcitabine-based in 28%.
At median follow-up of 24 months, 49/71 patients (69%) had failed. The predominant failure pattern was distant metastases in 35/71 patients (49%). The most common site of metastases was the liver. Fourteen patients (19%) developed locoregional failure in the tumor bed alone in 5 patients, regional nodes in 4 patients, and concurrently with metastases in 5 patients. Median overall survival (OS) was 25 months. On univariate analysis, nodal status, margin status, postoperative CA 19-9 level, and weight loss during treatment were predictive for OS. On multivariate analysis, higher postoperative CA19-9 levels predicted for worse OS on a continuous basis (p < 0.01). A trend to worse OS was seen among patients with more weight loss during therapy (p = 0.06). Patients with positive nodes and positive margins also had significantly worse OS (HR for death 2.8, 95% CI 1.1-7.5; HR for death 2.6, 95% CI 1.1-6.2, respectively). Grade 3-4 nausea and vomiting was seen in 8% of patients. Late complication of small bowel obstruction occurred in 4 (6%) patients.
This is the first comprehensive report of patterns of failure among patients treated with adjuvant IMRT for pancreas cancer. IMRT was not associated with an increase in local recurrences in our cohort. These data support the use of IMRT in the recently activated EORTC/US Intergroup/RTOG 0848 adjuvant pancreas trial.
调强放疗（IMRT）越来越多地被应用于胰腺癌的治疗。人们担心这种技术可能会导致地理上的遗漏和局部控制率下降。我们分析了接受 IMRT 治疗的可切除胰腺癌患者首次失败的模式。
本报告纳入了 71 例接受胰腺切除术和辅助放化疗的患者。所有患者均接受 IMRT 治疗，中位剂量为 50.4Gy。同步化疗在 72%的患者中采用 5-FU 为基础的方案，在 28%的患者中采用吉西他滨为基础的方案。
中位随访 24 个月时，71 例患者中有 49 例（69%）发生了失败。主要失败模式为远处转移 35 例（49%）。最常见的转移部位是肝脏。14 例（19%）患者仅在肿瘤床部位发生局部区域复发 5 例，区域淋巴结 4 例，同时发生转移 5 例。中位总生存期（OS）为 25 个月。单因素分析显示，淋巴结状态、切缘状态、术后 CA19-9 水平和治疗期间体重减轻与 OS 相关。多因素分析显示，术后 CA19-9 水平越高，OS 越差（p<0.01）。治疗期间体重减轻较多的患者 OS 较差（p=0.06）。阳性淋巴结和阳性切缘的患者 OS 明显更差（死亡风险比为 2.8，95%CI 1.1-7.5；死亡风险比为 2.6，95%CI 1.1-6.2）。8%的患者出现 3-4 级恶心和呕吐。4 例（6%）患者发生小肠梗阻的晚期并发症。
这是首项关于接受辅助 IMRT 治疗的胰腺癌患者失败模式的综合报告。在我们的队列中，IMRT 并未增加局部复发率。这些数据支持在最近启动的 EORTC/US 联合/RTOG 0848 辅助胰腺试验中使用 IMRT。
