术前化疗和立体定向体部放疗联合切除术治疗边界可切除或局部进展期胰腺癌患者的失败模式。

Patterns of Failure Following Preoperative Chemotherapy and Stereotactic Body Radiation Therapy and Resection for Patients with Borderline Resectable or Locally Advanced Pancreatic Cancer.

机构信息

Georgetown University School of Medicine, Washington, DC, USA.

Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA.

出版信息

J Gastrointest Cancer. 2024 Jun;55(2):852-861. doi: 10.1007/s12029-023-00996-3. Epub 2024 Feb 13.

DOI:10.1007/s12029-023-00996-3

PMID:38347342

Abstract

BACKGROUND

The role of neoadjuvant stereotactic body radiation therapy (SBRT) in the treatment of pancreatic adenocarcinoma (PDAC) is controversial and the optimal target volumes and dose-fractionation are unclear. The aim of this study is to report on treatment outcomes and patterns of failure of patients with borderline resectable (BL) or locally advanced (LA) pancreatic cancer following preoperative chemotherapy and SBRT.

METHODS

We conducted a single-institution, retrospective study of patients with BL or LA PDAC. Patients received neoadjuvant chemotherapy and SBRT was prescribed to 30 Gy over 5 fractions to the pancreas planning tumor volume (PTV). A subset of patients received a simultaneous integrated boost to the high risk vascular PTV and/or elective nodal irradiation (ENI). Following neoadjuvant chemoradiation, all patients underwent subsequent resection. Overall survival (OS), progression-free survival (PFS), locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMPFS), and locoregional control (LRC) estimates were obtained using Kaplan-Meier analysis.

RESULTS

Twenty-two patients with BL (18) or LA (4) PDAC were treated with neoadjuvant chemotherapy and SBRT followed by resection from 2011-2022. Following neoadjuvant treatment, 5 patients (23%) achieved a pathologic complete response (pCR) and 16 patients (73%) had R0 resection. At 24 months, there were no isolated locoregional recurrences (LRRs), 9 isolated distant recurrences (DRs), and 5 combined LRRs and DRs. Two LRRs were in-field, 2 LRRs were marginal, and 1 LRR was both in-field and marginal. 2-year median LRC, LRRFS, DMPFS, PFS, and OS were 77.3%, 45.5%, 31.8%, 31.8%, and 59.1%, respectively. For BL and LA cancers, 2-year LRC, DMPFS, and OS were 83% vs. 75%, (p = 0.423), 39% vs. 0% (p = 0.006), and 61% vs. 50% (p = 0.202), respectively. ENI was associated with improved LRC (p = 0.032) and LRRFS (p = 0.033). Borderline resectability (p = 0.018) and lower tumor grade (p = 0.027) were associated with improved DMPFS.

CONCLUSIONS

Following preoperative chemotherapy and SBRT, locoregional failure outside of the target volume occurred in 3 of 5 recurrences; ENI was associated with improved LRC and LRRFS. Further studies are necessary to define the optimal techniques for preoperative radiation therapy.

摘要

背景

新辅助立体定向体放射治疗（SBRT）在胰腺腺癌（PDAC）治疗中的作用存在争议，最佳靶区体积和剂量分割尚不清楚。本研究旨在报告接受新辅助化疗的边界可切除（BL）或局部晚期（LA）胰腺癌患者的治疗结果和失败模式，以及 SBRT 治疗。

方法

我们对 BL 或 LA PDAC 患者进行了单机构回顾性研究。患者接受新辅助化疗，并对胰腺计划肿瘤体积（PTV）进行 30 Gy/5 次分割的 SBRT。部分患者接受高危血管 PTV 和/或选择性淋巴结照射（ENI）的同时整合增强。新辅助放化疗后，所有患者均接受后续手术切除。采用 Kaplan-Meier 分析获得总生存（OS）、无进展生存（PFS）、局部区域无复发生存（LRRFS）、远处无复发生存（DMPFS）和局部区域控制（LRC）估计。

结果

2011 年至 2022 年，22 例 BL（18 例）或 LA（4 例）PDAC 患者接受新辅助化疗和 SBRT 治疗，然后行切除术。新辅助治疗后，5 例（23%）患者达到病理完全缓解（pCR），16 例（73%）患者行 R0 切除。24 个月时，无孤立性局部区域复发（LRR），9 例孤立性远处复发（DR），5 例 LRR 和 DR 合并。2 例 LRR 为场内，2 例 LRR 为边缘性，1 例 LRR 为场内和边缘性。2 年中位 LRC、LRRFS、DMPFS、PFS 和 OS 分别为 77.3%、45.5%、31.8%、31.8%和 59.1%。BL 和 LA 癌症的 2 年 LRC、DMPFS 和 OS 分别为 83% vs. 75%（p=0.423）、39% vs. 0%（p=0.006）和 61% vs. 50%（p=0.202）。ENI 与 LRC（p=0.032）和 LRRFS（p=0.033）的改善相关。边界可切除性（p=0.018）和较低的肿瘤分级（p=0.027）与 DMPFS 的改善相关。