Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
David M. Rubenstein Center for Pancreatic Cancer Research, New York, New York.
JAMA Oncol. 2021 May 1;7(5):735-738. doi: 10.1001/jamaoncol.2021.0057.
Surgical resection has been considered the only curative option for patients with pancreatic cancer. Nonoperative local treatment options that can provide a similar benefit are needed. Emerging radiation techniques that address organ motion have enabled curative radiation doses to be given in patients with inoperable disease.
To determine the association of hypofractionated ablative radiation therapy (A-RT) with survival for patients with locally advanced pancreatic cancer (LAPC) treated with a novel radiation planning and delivery technique.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study included 119 consecutive patients treated with A-RT between June 2016 and February 2019 and enrolled in a prospectively maintained database. Patients were treated with a standardized technique within a large academic cancer center regional network. All patients with localized, unresectable, or medically inoperable pancreatic cancer with tumors of any size and less than 5 cm luminal abutment with the primary tumor were eligible.
Ablative RT (98 Gy biologically effective dose) was delivered using standard equipment. Respiratory gating, soft tissue image guidance, and selective adaptive planning were used to address organ motion and limit the dose to surrounding luminal organs.
The primary outcome was overall survival (OS). Secondary outcomes included incidence of local progression and progression-free survival.
Between 2016 and 2019, 119 patients (59 men, median age 67 years) received A-RT, including 99 with T3/T4 and 53 with node-positive disease, with a median carbohydrate antigen 19-9 (CA19-9) level greater than 167 U/mL. Most (116 [97.5%]) received induction chemotherapy for a median of 4 months (0.5-18.4). Median OS from diagnosis and A-RT were 26.8 and 18.4 months, respectively. Respective 12- and 24-month OS from A-RT were 74% (95% CI, 66%-83%) and 38% (95% CI, 27%-52%). Twelve- and 24-month cumulative incidence of locoregional failure were 17.6% (95% CI, 10.4%-24.9%) and 32.8% (95% CI, 21.6%-44.1%), respectively. Postinduction CA19-9 decline was associated with improved locoregional control and survival. Grade 3 upper gastrointestinal bleeding occurred in 10 patients (8%) with no grade 4 to 5 events.
This cohort study of patients with inoperable LAPC found that A-RT following multiagent induction therapy for LAPC was associated with durable locoregional tumor control and favorable survival. Prospective randomized trials in patients with LAPC are warranted.
手术切除一直被认为是胰腺癌患者的唯一治愈选择。需要提供非手术局部治疗选择，以提供类似的益处。新兴的能够解决器官运动的放射技术使无法手术的疾病患者能够接受治愈剂量的放射。
确定采用新的放射规划和递送技术治疗局部晚期胰腺癌（LAPC）的患者，接受短分割消融放射治疗（A-RT）与生存的相关性。
设计、设置和参与者：这项队列研究纳入了 2016 年 6 月至 2019 年 2 月期间接受 A-RT 治疗的 119 例连续患者，并纳入了一个前瞻性维护的数据库。在大型学术癌症中心区域网络内，患者接受标准化技术治疗。所有局部进展期、不可切除或医学上不可手术的胰腺癌患者，肿瘤大小不限，与原发肿瘤的管腔毗邻小于 5cm 均符合条件。
使用标准设备提供消融性放射治疗（98Gy 生物有效剂量）。采用呼吸门控、软组织图像引导和选择性适应性计划，以解决器官运动问题并限制周围管腔器官的剂量。
主要结局是总生存（OS）。次要结局包括局部进展发生率和无进展生存期。
2016 年至 2019 年，119 例患者（59 例男性，中位年龄 67 岁）接受了 A-RT，包括 99 例 T3/T4 期和 53 例淋巴结阳性疾病，中位癌胚抗原 19-9（CA19-9）水平高于 167U/ml。大多数（116[97.5%]）接受了中位 4 个月（0.5-18.4 个月）的诱导化疗。从诊断到 A-RT 的中位 OS 分别为 26.8 个月和 18.4 个月。分别从 A-RT 开始的 12 个月和 24 个月的 OS 为 74%（95%CI，66%-83%）和 38%（95%CI，27%-52%）。12 个月和 24 个月时的局部区域失败累积发生率分别为 17.6%（95%CI，10.4%-24.9%）和 32.8%（95%CI，21.6%-44.1%）。诱导后 CA19-9 下降与局部区域控制和生存改善相关。10 例（8%）患者出现 3 级上消化道出血，无 4 级或 5 级事件。
这项针对不可切除的 LAPC 患者的队列研究发现，LAPC 患者接受多模式诱导治疗后进行 A-RT 与持久的局部区域肿瘤控制和有利的生存相关。需要在 LAPC 患者中进行前瞻性随机试验。
