Wo Jennifer Y, Niemierko Andrzej, Ryan David P, Blaszkowsky Lawrence S, Clark Jeffrey W, Kwak Eunice L, Lillemoe Keith D, Drapek Lorraine N, Zhu Andrew X, Allen Jill N, Faris Jason E, Murphy Janet E, Nipp Ryan, Fernandez-Del Castillo Carlos, Ferrone Cristina R, Hong Theodore S
Departments of Radiation Oncology.
Medical Oncology.
Am J Clin Oncol. 2018 Jul;41(7):656-661. doi: 10.1097/COC.0000000000000349.
We reviewed our experience involving patients with borderline resectable or locally advanced pancreatic cancer, treated with the dose-painted (DP) boost technique to regions of vessel involvement which preclude upfront surgical resection. We evaluated patient outcomes with respect to tolerability and treatment outcomes.
We retrospectively reviewed 99 patients with borderline resectable (n=25) or locally advanced pancreatic cancer (n=74) treated with DP-neoadjuvant chemoradiation from 2010 to 2015. Tumor and regional lymph nodes were prescribed 50.4 Gy and the region around the involved blood vessel was boosted to 58.8 Gy in 28 fractions. The primary outcome was acute toxicity and late duodenal toxicity. Secondary outcomes included conversion to surgical resectability, local failure, disease-free survival, and overall survival (OS). Cox proportional hazards models were performed to evaluate for predictors of survival.
All but 1 patient completed chemoradiation. The rates of grade 2+ and 3+ nausea were 40% and 12%, respectively. With regards to late toxicity, 5 patients developed potential RT-related grade 3+ duodenal complications including duodenal ulceration/bleeding (n=3) and duodenal stricture (n=2). With a median follow-up of 15 months, the median OS was 18.1 months. Among 99 patients in our study, 37 patients underwent surgical resection. For patients who underwent surgical resection (n=37), the median OS was 30.9 months. On multivariate analysis, only normalization of CA 19-9 post-RT was associated with improved OS.
We found that DP-neoadjuvant chemoradiation to regions of vessel involvement is both feasible and well tolerated. In addition, we demonstrated that over one third of patients with initially deemed unresectable disease were able to undergo surgical resection after receiving neoadjuvant therapy including DP-chemoradiation.
我们回顾了我们对临界可切除或局部晚期胰腺癌患者的治疗经验，这些患者采用剂量描绘（DP）增敏技术治疗血管受累区域，这些区域排除了 upfront 手术切除的可能性。我们评估了患者在耐受性和治疗结果方面的情况。
我们回顾性分析了 2010 年至 2015 年期间接受 DP 新辅助放化疗的 99 例临界可切除（n = 25）或局部晚期胰腺癌（n = 74）患者。肿瘤和区域淋巴结的处方剂量为 50.4 Gy，受累血管周围区域分 28 次增敏至 58.8 Gy。主要结局是急性毒性和晚期十二指肠毒性。次要结局包括转为手术可切除性、局部失败、无病生存期和总生存期（OS）。采用 Cox 比例风险模型评估生存预测因素。
除 1 例患者外，所有患者均完成了放化疗。2 级及以上和 3 级及以上恶心的发生率分别为 40%和 12%。关于晚期毒性，5 例患者出现了潜在的与放疗相关的 3 级及以上十二指肠并发症，包括十二指肠溃疡/出血（n = 3）和十二指肠狭窄（n = 2）。中位随访 15 个月，中位 OS 为 18.1 个月。在我们研究的 99 例患者中，37 例接受了手术切除。对于接受手术切除的患者（n = 37），中位 OS 为 30.9 个月。多因素分析显示，只有放疗后 CA 19-9 正常化与 OS 改善相关。
我们发现对血管受累区域进行 DP 新辅助放化疗既可行且耐受性良好。此外，我们证明超过三分之一最初被认为不可切除的疾病患者在接受包括 DP 放化疗在内的新辅助治疗后能够接受手术切除。
