Published online Apr 27, 2017. doi: 10.4240/wjgs.v9.i4.103
Peer-review started: November 23, 2016
First decision: December 29, 2016
Revised: January 28, 2017
Accepted: March 12, 2017
Article in press: March 13, 2017
Published online: April 27, 2017
To review surgical outcomes for patients undergoing pancreatectomy after proton therapy with concomitant capecitabine for initially unresectable pancreatic adenocarcinoma.
From April 2010 to September 2013, 15 patients with initially unresectable pancreatic cancer were treated with proton therapy with concomitant capecitabine at 1000 mg orally twice daily. All patients received 59.40 Gy (RBE) to the gross disease and 1 patient received 50.40 Gy (RBE) to high-risk nodal targets. There were no treatment interruptions and no chemotherapy dose reductions. Six patients achieved a radiographic response sufficient to justify surgical exploration, of whom 1 was identified as having intraperitoneal dissemination at the time of surgery and the planned pancreatectomy was aborted. Five patients underwent resection. Procedures included: Laparoscopic standard pancreaticoduodenectomy (n = 3), open pyloris-sparing pancreaticoduodenectomy (n = 1), and open distal pancreatectomy with irreversible electroporation (IRE) of a pancreatic head mass (n = 1).
The median patient age was 60 years (range, 51-67). The median duration of surgery was 419 min (range, 290-484), with a median estimated blood loss of 850 cm3 (range, 300-2000), median ICU stay of 1 d (range, 0-2), and median hospital stay of 10 d (range, 5-14). Three patients were re-admitted to a hospital within 30 d after discharge for wound infection (n = 1), delayed gastric emptying (n = 1), and ischemic gastritis (n = 1). Two patients underwent R0 resections and demonstrated minimal residual disease in the final pathology specimen. One patient, after negative pancreatic head biopsies, underwent IRE followed by distal pancreatectomy with no tumor seen in the specimen. Two patients underwent R2 resections. Only 1 patient demonstrated ultimate local progression at the primary site. Median survival for the 5 resected patients was 24 mo (range, 10-30).
Pancreatic resection for patients with initially unresectable cancers is feasible after high-dose [59.4 Gy (RBE)] proton radiotherapy with a high rate of local control, acceptable surgical morbidity, and a median survival of 24 mo.
Core tip: Patients undergoing pancreatectomy for resectable pancreas cancers have a significant risk of local and regional recurrence. That risk could be reduced if patients received moderate-dose preoperative radiotherapy. Many surgeons, however, are concerned that conventional X-ray-based radiotherapy could complicate what is already a complicated operation. The current series documents the surgical outcomes for 15 patients with initially unresectable pancreatic cancers who underwent pancreatectomy after high-dose [59.40 Gy (RBE)] proton-based radiotherapy. The lack of increased surgical toxicity suggests that proton radiotherapy may represent an optimal vehicle for the delivery of moderate dose neoadjuvant radiotherapy in the setting of resectable disease.