Adjuvant therapeutic strategies for resectable pancreatic adenocarcinoma

Abstract

Of all patients diagnosed with pancreatic adenocarcinoma, only 15-20% present with resectable disease. Despite curative-intent resection, the prognosis remains poor with the majority of patients recurring, prompting the need for adjuvant therapy. Historical data support the use of adjuvant 5-fluorouracil (5-FU) or gemcitabine, but recent data suggest either gemcitabine plus capecitabine or modified FOLFIRINOX can improve overall survival when compared to gemcitabine alone. The use of adjuvant chemoradiation therapy remains controversial, primarily due to limitations in study design and mixed results of historical trials. The ongoing Radiation Therapy Oncology Group (RTOG)-0848 trial hopes to further define the role of adjuvant chemoradiation therapy. Intraoperative radiation therapy (IORT) and adjuvant immunotherapy represent additional possibilities to improve outcomes, but evidence supporting their use is limited. This article reviews adjuvant therapeutic strategies for resectable pancreatic adenocarcinoma, including chemotherapy, chemoradiation therapy, IORT and immunotherapy.

Keywords: Resectable pancreatic adenocarcinoma; adjuvant; chemoradiation; chemotherapy; outcomes.

Figure 1

(A) Coronal and (B) sagittal views of an IMRT plan for a pT3N0 pancreatic adenocarcinoma, resected to negative margins and with 0/15 lymph nodes. The patient received 5,040 cGy in 180 cGy per fraction with concurrent twice daily capecitabine. This field encompassed the preoperative tumor volume, surgical margin, PJ, choledocojejunostomy, celiac axis, SMA and vein, porta hepatis, and paraaortic lymph nodes. This plan incorporated 6 MV photons and non-coplanar fields to better spare the liver and kidneys. Also, 4-dimensional computed tomography simulation with abdominal compression was employed to allow for reproducibility of respiratory motion. IMRT, intensity-modulated radiation therapy; PJ, pancreaticojejunostomy; SMA, superior mesenteric artery.