The integration of chemoradiation in the care of patient with localized pancreatic cancer

• Published in: Cancer radiothérapie 2009-04, Vol.13 (2), p.123-143
• Main Authors: Crane, C.H., Varadhachary, G., Settle, S.H., Fleming, J.B., Evans, D.B., Wolff, R.A.
• Format: Article
• Language: English
• Subjects: Antimetabolites, Antineoplastic - therapeutic use; Antineoplastic agents; Biological and medical sciences; Biopsy, Fine-Needle; Cancer du pancréas; Capecitabine; Chemoradiation; Chimioradiothérapie; Clinical Trials as Topic; Combined Modality Therapy; Combined treatments (chemotherapy of immunotherapy associated with an other treatment); Deoxycytidine - analogs & derivatives; Deoxycytidine - therapeutic use; Diagnostic Imaging; Fluorouracil - analogs & derivatives; Fluorouracil - therapeutic use; Gemcitabine; Humans; Medical sciences; Pancreatic cancer; Pancreatic Neoplasms - diagnosis; Pancreatic Neoplasms - therapy; Pharmacology. Drug treatments; Tumors
• ISSN: 1278-3218; 1769-6658
• DOI: 10.1016/j.canrad.2008.11.008

The use of chemoradiation for patients with localized pancreatic cancer is controversial. Although some randomized trials have indicated that chemoradiation improves the median survival of patients with locally advanced as well as resected pancreatic cancer, other more recent trials have called into question the role of chemoradiation and have supported the use of chemotherapy. In the adjuvant setting, the high local tumor recurrence/persistence rate in all trials probably reflects the inclusion of patients with incompletely resected tumors, whose prognosis is similar to the prognosis of patients with locally advanced who do not undergo resection, making these trials difficult to interpret. More precise clinical staging and selection of patients appropriate for surgical resection is an important goal. The keys to the successful integration of radiotherapy in the care of patients with localized pancreatic cancer are selection, sequencing and smaller treatment volumes. A strategy of initial chemotherapy followed by consolidation with a well-tolerated chemoradiation regimen both in the adjuvant and locally advanced settings maximizes benefits of both treatment options, which are in fact complementary. Herein, we discuss the rationale for this approach as well as the ongoing investigation of novel radiation approaches designed to enhance outcome through the molecular and physical targeting of disease as well as the investigation of neoadjuvant chemoradiation in radiographically resectable and borderline resectable pancreatic cancer. La chimioradiothérapie est controversée dans la prise en charge du cancer du pancréas localisé. Quoique les essais randomisés aient montré que la chimioradiothérapie augmente la durée médiane de survie chez les patients atteints de cancer localement évolué ou réséqué, d’autres ont plus récemment remis en question le rôle de la chimioradiothérapie au profit de la chimiothérapie. Le taux élevé de récidives/tumeurs non stérilisées observé dans tous les essais de traitements adjuvants reflète probablement l’inclusion de patients chez qui la résection a été incomplète. La conséquence en est un pronostic similaire à celui des tumeurs localement évoluées, qui ne sont pas réséquées, ce qui en rend l’interprétation des essais difficile. Un staging plus précis et une sélection plus rigoureuse des patients qui doivent être opérés sont nécessaires. Les clés d’une meilleure intégration de la radiothérapie dans la prise en charge des cancers loc