Pendurthi T K, Hoffman J P, Ross E, Johnson D E, Eisenberg B L
Department of Surgery, Fox Chase Cancer Center, Philadelphia, Pennsylvania 19111, USA.
Am Surg. 1998 Jul;64(7):686-92.
Two groups of patients with adenocarcinoma of the pancreas treated with either preoperative chemoradiation (preop CTRT) or postoperative chemoradiation (postop CTRT) were retrospectively analyzed for various treatment-related parameters. Between November 1986 and October 1996, a total of 70 patients with pancreatic adenocarcinoma were enrolled into preop CTRT protocols at our institution. Twenty-five patients with adenocarcinoma of the head of the pancreas underwent pancreaticoduodenectomy with curative intent. After the closure of the preop CTRT protocols, we had the opportunity to perform 23 pancreatic resections without preop CTRT. After surgery, these patients were advised to undergo CTRT. These two groups of patients were therefore selected consecutively, dependent only on the time of referral and no other bias. These two cohorts of patients are compared for various intraoperative parameters, length of hospital stay, pathologic findings, time to recurrence, and survival. Mean age was 65 and 66 years in the preop and postop CTRT groups, respectively. Sex distribution was almost equal. Treatment breaks resulting in greater than 1 week delay in the radiotherapy occurred in 2 (8%) of 25 patients in the preop CTRT group (myelotoxicity in 1 case and biliary sepsis in 1 case), whereas no treatment breaks >1 week occurred in those receiving postop CTRT. Eleven patients in preop CTRT had grade 3 or 4 toxicity, whereas none was noted in those with postop CTRT. There was one postoperative death in the preop CTRT group and none in the postop CTRT group. Mean time to the start of CTRT was 45 days (range, 20-66 days) after pancreaticoduodenectomy. Delay of >60 days to the onset of CTRT occurred in 2 (22%) patients and was attributable to patient delays in time to recover from surgery or patient noncompliance. Furthermore, 5 of 23 patients (22%) in the postop CTRT group did not receive treatment for various reasons. Average estimated operative blood loss was 1933 mL (median 1550) and 1060 mL (median 1000) for preop and postop CTRT groups, respectively. Mean length of operation was 488 minutes (median 480) and 486 minutes (median 480). Median length of postoperative stay was 22 and 20 days (ranges, 9-144 and 10-38). Pathological findings in the resected specimens showed significantly fewer involved nodes in the preop CTRT group (28 vs 87%; P = 0.0006), whereas similar numbers of nodes/patient were counted in each group (14 vs 22, P = 0.11). More negative resection margins were observed in the preop CTRT group (28 vs 56%; P = not significant). A significantly greater amount of fibrosis replacing the tumor was observed in the preop CTRT group (70 vs 40%; P = 0.0001). There were no significant survival differences observed (median 20 months vs 25 months; P = 0.48), in follow-up that ranged from 4 to 76 months (median 44 months for surviving patients) for the preop group and 4 to 40 months (median 16 months for surviving patients) for those with postop CTRT. Local failure either alone or as a component of distant failure occurred in 16 per cent (4 of 25 patients) with preop CTRT and 16.6 per cent (3 of 18) with postop CTRT. Analysis of differences between those treated with preoperative and postoperative CTRT demonstrates similarity in toxicity and effects. However, 22 per cent of patients intended for postoperative therapy did not receive treatment.
对两组分别接受术前放化疗（preop CTRT）或术后放化疗（postop CTRT）的胰腺癌患者的各种治疗相关参数进行了回顾性分析。1986年11月至1996年10月期间，共有70例胰腺癌患者在我院纳入术前放化疗方案。25例胰头腺癌患者接受了根治性胰十二指肠切除术。在术前放化疗方案结束后，我们有机会对23例未接受术前放化疗的患者进行胰腺切除术。术后，建议这些患者接受放化疗。因此，这两组患者是连续入选的，仅取决于转诊时间，无其他偏倚。比较这两组患者的各种术中参数、住院时间、病理结果、复发时间和生存率。术前和术后放化疗组的平均年龄分别为65岁和66岁。性别分布几乎相等。术前放化疗组25例患者中有2例（8%）放疗中断超过1周（1例为骨髓毒性，1例为胆系感染），而接受术后放化疗的患者未出现超过1周的治疗中断。术前放化疗组有11例患者出现3级或4级毒性反应，而术后放化疗组未发现。术前放化疗组有1例术后死亡，术后放化疗组无死亡。胰十二指肠切除术后开始放化疗的平均时间为45天（范围20 - 66天）。2例（22%）患者放化疗开始延迟>60天，原因是患者从手术恢复时间延迟或患者不依从。此外，术后放化疗组23例患者中有5例（22%）因各种原因未接受治疗。术前和术后放化疗组的平均估计手术失血量分别为1933 mL（中位数1550）和1060 mL（中位数1000）。平均手术时间为488分钟（中位数480）和486分钟（中位数480）。术后住院时间中位数分别为22天和20天（范围9 - 144天和10 - 38天）。切除标本的病理结果显示，术前放化疗组受累淋巴结明显较少（28%对87%；P = 0.0006），而每组患者计数的淋巴结数量相似（14个对22个，P = 0.11）。术前放化疗组观察到更多的阴性切缘（28%对56%；P = 无显著性差异）。术前放化疗组观察到取代肿瘤的纤维化程度明显更高（70%对40%；P = 0.0001）。随访时间为4至76个月（存活患者中位数44个月）的术前放化疗组和4至40个月（存活患者中位数16个月）的术后放化疗组，未观察到显著的生存差异（中位数20个月对25个月；P = 0.48）。术前放化疗组16%（25例中的4例）和术后放化疗组16.6%（18例中的3例）出现单独局部失败或作为远处失败的一部分。对术前和术后接受放化疗患者的差异分析表明，毒性和效果相似。然而，22%计划接受术后治疗的患者未接受治疗。
