Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Apr 27, 2017; 9(4): 103-108
Published online Apr 27, 2017. doi: 10.4240/wjgs.v9.i4.103
Feasibility of pancreatectomy following high-dose proton therapy for unresectable pancreatic cancer
Kathryn E Hitchcock, R Charles Nichols, Christopher G Morris, Debashish Bose, Steven J Hughes, John A Stauffer, Scott A Celinski, Elizabeth A Johnson, Robert A Zaiden, Nancy P Mendenhall, Michael S Rutenberg
Kathryn E Hitchcock, R Charles Nichols, Christopher G Morris, Nancy P Mendenhall, Michael S Rutenberg, Department of Radiation Oncology, University of Florida, Jacksonville, FL 32206, United States
Debashish Bose, Department of Surgical Oncology, UF Health Cancer Center - Orlando Health, Orlando, FL 32806, United States
Steven J Hughes, Department of Surgery, University of Florida, Gainesville, FL 32610, United States
John A Stauffer, Department of Surgery, Mayo Clinic, Jacksonville, FL 32224, United States
Scott A Celinski, Department of Surgery, Baylor University Medical Center at Dallas, Dallas, TX 75246, United States
Elizabeth A Johnson, Department of Hematology/Oncology, Mayo Clinic, Jacksonville, FL 32610, United States
Robert A Zaiden, Department of Hematology/Oncology, Baptist Health, Jacksonville, FL 32610, United States
Author contributions: Hitchcock KE, Nichols RC and Rutenberg MS wrote the manuscript; Bose D, Hughes SJ, Stauffer JA, Celinski SA, Johnson EA, Zaiden RA and Mendenhall NP reviewed the manuscript; Morris CG performed statistical analysis; Bose D, Hughes SJ, Stauffer JA, Celinski SA, Johnson EA and Zaiden RA provided patient care.
Institutional review board statement: The University of Florida Health Proton Therapy Institute’s PC-O1 and outcomes-tracking study were approved by an institutional review board at the University of Florida College of Medicine in Jacksonville, FL.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors of this current series have no conflicts of interested to disclose.
Data sharing statement: No additional data are available.
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/
Correspondence to: R Charles Nichols, MD, Department of Radiation Oncology, University of Florida, 2015 North Jefferson St. Jacksonville, FL 32206, United States. rnichols@floridaproton.org
Telephone: +1-904-5881800 Fax: +1-904-5881300
Received: November 17, 2016
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.

Keywords: Pancreatic cancer, Pancreatectomy, Pancreas, Proton therapy, Radiotherapy

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.