Background and Purpose:
Neoadjuvant chemoradiation could improve survival in patients with pancreatic cancer because of a higher rate of R0 resections, lower rate of nodal metastasis (ypN) and of local recurrence. This approach was tested in a cohort to estimate its effect on survival.
Patients and Methods:
Three-dimensional, conformal radiation to the primary tumor (55.8 Gy) and the lymphatics (50.4 Gy) was combined with chemotherapy. Resection was performed 6 weeks after completion of chemoradiation.
Results:
38 of 120 patients with locally advanced cancer underwent tumor resection thereafter. Three patients (8%) had pathologic complete response. Median tumor-specific survival was 29 months and overall survival 25 months. Patients with clear margins (35/38; 89%) had a 3-year disease-specific survival rate of 51% versus 0% with positive margins (p = 0.008). Nodal disease rate decreased from 50% at pretherapeutic imaging to 32% at resection. Patients with ypN0 status (n = 26/38) had a 3-year tumor-specific survival rate of 50% compared to 31% in patients with ypN1 status. At multivariate analysis, resection status and nodal spread significantly predicted tumor-specific survival. Chemoradiation was generally well tolerated.
Conclusion:
The current results support randomized testing of neoadjuvant chemoradiation to prove survival prolongation. Compared to the literature this approach seems to reduce the number of positive nodes.
Hintergrund und Ziel:
Neoadjuvante Radiochemotherapie kann die Überlebenszeit von Patienten mit Pankreaskarzinomen potentiell verlängern, da eine höhere Rate von R0-Resektionen sowie eine niedrigere Rate von Lymphknotenmetastasen (ypN) und Lokalrezidiven erzielt werden. Dazu wurde dieser Ansatz in einer Kohorte von Patienten mit Pankreaskarzinomen untersucht.
Patienten und Methodik:
Der Primärtumor (Dosis 55,8 Gy) und das Lymphabflussgebiet (Dosis 50,4 Gy) wurden dreidimensional konformal bestrahlt mit simultaner Chemotherapie. 6 Wochen danach wurde reseziert.
Ergebnisse:
Die Tumoren von 38 von 120 Patienten mit lokal fortgeschrittenen Tumoren wurden reseziert. Drei Patienten (8%) zeigten eine pathologisch komplette Remission. Die mediane tumorspezifische Überlebenszeit betrug 29 Monate und die mediane Gesamtüberlebenszeit 25 Monate. Patienten mit R0-Resektion (35/38; 89%) wiesen eine krankheitsspezifische 3-Jahres-Überlebensrate von 51% versus 0% nach R1-Resektion auf (p = 0,008). Der Lymphknotenbefall nahm von 50% in der prätherapeutischen Bildgebung auf 32% bei der Resektion ab. Bei Patienten mit ypN0-Status (n = 26/38) fand sich eine krankheitsspezifische 3-Jahres-Überlebensrate von 50% im Vergleich zu 31% bei Patienten mit ypN1-Status. In der multivariaten Analyse waren der Resektionsstatus und der Lymphknotenbefall signifikante Prädiktoren des tumorspezifischen Überlebens. Die Radiochemotherapie wurde generell gut vertragen.
Schlussfolgerung:
Die Ergebnisse unterstützen die randomisierte Prüfung der neoadjuvanten Radiochemotherapie, um eine Überlebensverlängerung zu bestätigen. Im Literaturvergleich scheint dieser Ansatz die Anzahl befallener Lymphknoten zu reduzieren.
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Tinkl, D., Grabenbauer, G.G., Golcher, H. et al. Downstaging of Pancreatic Carcinoma after Neoadjuvant Chemoradiation. Strahlenther Onkol 185, 557–566 (2009). https://doi.org/10.1007/s00066-009-1977-9
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DOI: https://doi.org/10.1007/s00066-009-1977-9