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Neoadjuvant Chemoradiotherapy for Locally Advanced Pancreas Cancer Does Not Lead to Radiologic Tumor Regression
Vikas Dudeja*1, Sidney P. Walker2, Edward W. Greeno3, Eric H. Jensen1
1Surgery, University of Minnesota, Minnespolis, MN; 2Radiology, University of Minnesota, Minneapolis, MN; 3Medical Oncology, University of Minnesota, Minneapolis, MN
INTRODUCTION: Neo-adjuvant chemo-radiotherapy is proposed to improve resectability of locally-advanced/borderline-resectable pancreas cancer (LAPC). The ability of neo-adjuvant therapy to provide tumor regression has not been reported.
METHODS: We reviewed pre and post treatment CT scans of patients undergoing neo-adjuvant chemo-radiotherapy (cisplatin, interferon-alpha, 5-FU, radiation) in a phase II clinical trial for LAPC between 2005 and 2008. Response to therapy and rates of surgical resection were assessed.
RESULTS: 16 patients (median age 64years, males 69%) received neo-adjuvant therapy for LAPC during 2005-08 (table). Mean tumor size before neo-adjuvant treatment was 3.85cm. Indications for neo-adjuvant treatment included one or more of the following: Involvement of superior mesenteric artery (SMA) (≤180 degree-3 patients, >180 degree-1 patient), celiac axis (CA) (≤180 degree-2 patients, >180 degree-3 patients), hepatic artery (HA) (>180 degree-6 patients), and/or superior mesenteric vein/portal vein (SMV/PV) (≤180 degree-6 patients, >180 degree-7 patients). Regression of major vascular involvement, i.e. un-encasement or regression of abutment of any involved vessels was not observed in any patients. Pre-treatment and post-treatment CA19-9 levels as well as tumor density (Hounsfield units) were not statistically different. 50% of patients with borderline resectable disease (tumor involving ≤ 180 degree circumference of the SMA; short-segment encasement/abutment of the common HA; or tumor-associated deformity, abutment or short-segment occlusion of SMV/PV that was amenable to vascular resection and reconstruction) and none of the patients with locally advanced un-resectable pancreatic cancer (vascular involvement more than that described for borderline resectable pancreatic cancer) eventually underwent surgical resection. Out of 5 patients who eventually underwent resection, 4 had macroscopic tumor and 1 had only microscopic tumor.
CONCLUSION(S): Neo-adjuvant treatment does not provide tumor regression of LAPC with major vascular involvement. Patient selection for neo-adjuvant trial enrollment should remain focused on borderline disease which may have potential for surgical resection.
Patient and Tumor Characteristics.
| Age in years | | Median (range) | 64 (45-78) | | Gender: % (n) | | Male | 69% (11) | | Female | 31% (5) | | Explored before neoadjuvant chemoradiation: % (n) | | Yes | 31% (5) | | No | 69% (11) | | Location of tumor: % (n) | | Head | 69% (11) | | Body | 18% (3) | | Tail | 13% (2) | | Tumor size (mean±SD) | | Pre-Treatment | 3.85±1.92(NS) | | Post-Treatment | 3.39±1.81 | | Tumor extension at presentation: % (n) | | Borderline Resectable | 62.5% (10) | | Locally Advanced | 37.5% (5) | | CA 19-9 levels: | | Pre-Treatment | 1436±772 (NS) | | Post-Treatment | 772±220 | | Tumor density in Hounsfield units | | Pre-Treatment | 60.4±6.5 (NS) | | Post-Treatment | 58.2±6.9 | | Radiological Response: % (n) | | Regression | 6.25% (1) | | Stable | 56.25% (9) | | Progression | 37.5% (5) | | Surgical resection of cancer after neo-adjuvant chemoradiation: % (n) | | Yes | 31% (5) | | No | 69% (11) | | Patients undergoing surgical resection classified by tumor extension at presentation: %(n) | | Borderline Resectable | 50% (5) | | Locally Advanced | 0% (0) | | Pathologic response in those undergoing resection (n=5) | | Macroscopic tumor | 4 | | Microscopic tumor only | 1 |
NS: non significant.
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