Editoral
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jul 27, 2019; 11(7): 303-307
Published online Jul 27, 2019. doi: 10.4240/wjgs.v11.i7.303
Optimizing neoadjuvant radiotherapy for resectable and borderline resectable pancreatic cancer using protons
Romaine Charles Nichols, Michael Rutenberg
Romaine Charles Nichols, Michael Rutenberg, Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL 32206, United States
Author contributions: Nichols RC and Rutenberg MS equally contributed to this paper.
Conflict-of-interest statement: The authors have no conflicts of interest to disclose. Funding: None.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Romaine Charles Nichols, MD, Associate Professor, Department of Radiation Oncology, University of Florida College of Medicine, 015 North Jefferson Street, Jacksonville, FL 32206, United States. rnichols@floridaproton.org
Telephone: +1-904-5881245 Fax: +1-904-5881300
Received: May 16, 2019
Peer-review started: May 20, 2019
First decision: May 31, 2019
Revised: June 25, 2019
Accepted: July 25, 2019
Article in press: July 26, 2019
Published online: July 27, 2019
Abstract

Approximately 25% of patients diagnosed with pancreatic cancer present with non-metastatic resectable or borderline resectable disease. Unfortunately, the cure rate for these “curable” patients is only in the range of 20%. Local-regional failure rates may exceed 50% after margin-negative, node-negative pancreatectomy, but up to 80% of resections are associated with regional lymph node or margin positivity. While systemic drug therapy and chemotherapy may prevent or delay the appearance of distant metastases, it is unlikely to have a significant impact on local-regional disease control. Preoperative radiotherapy would represent a rational intervention to improve local-regional control. The barrier to preoperative radiotherapy is the concern that it could potentially complicate what is already a long and complicated operation. When the radiotherapy is delivered with X-rays (photons), the entire cylinder of the abdomen is irradiated; therefore, an operating surgeon may be reluctant to accept the associated risk of increased toxicity. When preoperative radiotherapy is delivered with protons, however, significant bowel and gastric tissue-sparing is achieved and clinical outcomes indicate that proton therapy does not increase the risk of operative complications nor extend the length of the procedure.

Keywords: Radiation oncology, Pancreatic cancer, Proton therapy

Core tip: Patients with resectable and borderline resectable pancreatic cancer are at a high risk of suffering postoperative local-regional failure. Preoperative radiotherapy directed to gross disease and regional lymphatic beds at high risk of harboring microscopic disease appears to be an oncologically rational intervention to reduce this risk. When proton-based radiotherapy addressing gross disease as well as high-risk regional lymphatic beds is delivered prior to surgery, it does not appear to increase the risk of surgical complications or the duration of surgery. Because of this, we would argue that proton-based preoperative radiotherapy should be considered for patients with resectable and borderline resectable disease.