Pancreatic adenocarcinoma: Adjuvant, neoadjuvant, and intraoperative chemoradiation

Recent data suggest that multimodality therapy including adjuvant or neoadjuvant chemoradiation may significantly improve the outcome of patients with resectable pancreatic cancer. A single randomized study by the Gastrointestinal Tumor Study Group showed that adjuvant 5-fluouracil (5-FU)- based chemoradiation extends survival in patients with resected pancreatic adenocarcinoma. Since then several other nonrandomized studies have supported this finding. Neoadjuvant chemoradiation also has been evaluated in this setting; this approach may increase the likelihood for margin-negative resection and thereby provide improved local control. However, associated survival benefits over traditional adjuvant therapy remain to be established. As an additional approach, several centers have evaluated intraoperative radiation therapy (IORT), in which patients receive radiation delivered to the pancreatic bed after apparently curative resection. A number of studies confirm that IORT can be delivered safely and may contribute to improved local control following surgical resection. Finally, an area of current focus involves the development of novel methods for more adequately assessing response to chemoradiation in pancreatic cancer. Clinicians recognize the inadequacy of computed tomography scans to assess response in this disease and have developed alternative endpoints including measurement of pre- and post-treatment serum CA 19-9 levels and ¹⁸F-fluorodeoxyglucose positron emission tomography to better evaluate patient response to therapy. We are currently using these modalities to assess response to paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ)-based neoadjuvant chemoradiation in patients with potentially resectable adenocarcinoma of the pancreatic head. Further studies will better define the role of new agents and more sophisticated means to assess tumor response in this disease.