review of literature on clinical pancreatology - The Pancreapedia

was observed in the NACRT group. The frequency <strong>of</strong> residual tumor grading in the NACRTgroup was significantly different from that in surgery-alone (R0/1/2 %, 52/15/33 vs 22/51/27).In R0/1 cases, overall survival and disease-free survival rates in the NACRT group (n=18)were significantly longer than in surgery-alone (n=30). The rate <strong>of</strong> local recurrence in theNACRT group was significantly less than in surgery-alone (11 % vs 47 %). It was concludedthat this single-institution experience indicates that neoadjuvant chemoradiation therapy isable to increase the resectability rate with clear margins and to decrease the rate <strong>of</strong>metastatic lymph nodes, resulting in improved prognosis <strong>of</strong> curative cases with pancreaticcancer that extended beyond the pancreas [526].Adjuvant chemoradiationThe role <strong>of</strong> adjuvant chemoradiation therapy (CRT) in pancreatic cancer remainscontroversial. The primary aim <strong>of</strong> one study was therefore to determine if CRT improvedsurvival in patients with resected pancreatic cancer in a large, multiinstitutional cohort <strong>of</strong>patients. Patients undergoing resection for pancreatic adenocarcinoma from seven academicmedical institutions were included. Exclusion criteria included patients with T4 or M1 disease,R2 resection margin, preoperative therapy, chemotherapy alone, or if adjuvant therapy statuswas unknown. There were 747 patients included in the initial evaluation. Primary analysiswas performed between patients that had surgery alone (n=374) and those receivingadjuvant CRT (n=299). Median follow-up time was 12 months and 15 months, respectively,for survivors. Median overall survival for patients receiving adjuvant CRT was significantlylonger than for those undergoing operation alone (20 vs 15 months). On subset andmultivariate analysis, adjuvant CRT demonstrated a significant survival advantage onlyamong patients who had lymph node (LN)-positive disease (hazard ratio 0.48, 95 % CI 0.36to 0.64) and not for LN-negative patients (hazard ratio 0.81, 95 % CI 0.56 to 1.18). Diseasefreesurvival in patients with LN-negative disease who received adjuvant CRT wassignificantly worse than in patients who had surgery alone (15 months vs 19 months). Thusthis large multiinstitutional study emphasizes the importance <strong>of</strong> analyzing subsets <strong>of</strong> patientswith pancreas adenocarcinoma who have LN metastasis. Benefit <strong>of</strong> adjuvant CRT is seenonly in patients with LN-positive disease, regardless <strong>of</strong> resection margin status. CRT inpatients with LN-negative disease may contribute to reduced disease-free survival [527].Pre- plus postoperative chemoradiationTo evaluate both the feasibility and efficacy <strong>of</strong> our combined therapy, which consisted <strong>of</strong>preoperative chemoradiation, surgery, and postoperative liver perfusion chemotherapy (LPC)for patients with T3 (extended beyond the pancreatic confines) cancer <strong>of</strong> the pankreas 38patients with T3-pancreatic cancers consented to receive a combination <strong>of</strong> preoperativechemoradiation, surgery, and postoperative LPC 2002 to 2007. With the aid <strong>of</strong> 3D radiationplanning, irradiation fields were constructed that included both the primary pancreatic tumorand retropancreatic tissues while taking care to exclude any section <strong>of</strong> the gastrointestinaltract. The total dose <strong>of</strong> radiation was 50 Gy (2 Gy x 25 fractions/5 weeks) and wasadministered in combination with gemcitabine treatments (1000 mg/m/week x 9/3 months).Preoperative restaging via computerized tomography and intraoperative inspection wereused to determine if pancreatectomy was indicated. For resected cases, one catheter wasplaced into the gastroduodenal artery and another one into the superior mesenteric vein.Postoperatively, 5-FU (125 mg/day x 28 days) was infused via each <strong>of</strong> these 2 routes.Preoperative chemoradiation was completed for all 38 patients, including 3 patients whorequired gemcitabine-dose reduction. Seven patients (18 %) did not undergo surgicalresection because either distant metastases or progressive local tumors had been detectedafter chemoradiation. The remaining 31 patients (82 %) underwent pancreatectomy pluspostoperative perfusion chemotherapy, without postoperative or in-hospital mortality. The 5-year survival rate after pancreatectomy was 53 percent, with low incidences <strong>of</strong> both localrecurrence (9 %) and liver metastasis (7 %). Postoperative histopathologic study revealed amarked degenerative change in cancer tissue, showing negative surgical margins (R0) for 30patients (96 %) and negative nodal involvement for 28 patients (90 %) [528].