Oncology

Metastatic Pancreatic Cancer

Neoadjuvant Therapy Without Radiation in Patients Undergoing Surgical Resection

clinical study insights by Margaret A. Tempero, MD

Overview

Clinical Study Abstract:

Background: No consensus exists regarding the optimal neoadjuvant treatment paradigm for patients with borderline resectable pancreatic cancer (BRPC), including the respective roles of chemotherapy and radiation.
Methods: We performed a retrospective analysis, including detailed pathologic and radiologic review, of pancreatic cancer patients undergoing FOLFIRINOX*, with or without radiation therapy (RT), prior to surgical resection at a high-volume academic center over a 4-year period.
Results: Of 26 patients meeting inclusion criteria, 22 (84.6%) received FOLFIRINOX alone without RT (median number of treatment cycles=9). The majority of patients met formal radiographic criteria for BRPC, with the superior mesenteric vein representing the most common vessel involved. R0 resection rate was 90.9%, with 12 patients (54.5%) requiring vascular reconstruction. Treatment response was classified as moderate or marked in 16 patients (72.7%) according to the grading system of the College of American Pathologists. Estimated median disease-free and overall survival rates are 22.6 months and not reached, respectively.
Conclusions: This is one of the largest series to describe the use of neoadjuvant FOLFIRINOX, without radiation therapy, in patients with BRPC undergoing surgical resection. Given the high R0 resection rates and favorable clinical outcomes with chemotherapy alone, this strategy should be further assessed in prospective study design.

*FOLFIRINOX: FOL=leucovorin calcium (folinic acid); F=5-fluorouracil; IRIN=irinotecan hydrochloride; OX=oxaliplatin.

References

Kim SS, Nakakura EK, Wang ZJ, et al. Preoperative FOLFIRINOX for borderline resectable pancreatic cancer: is radiation necessary in the modern era of chemotherapy? J Surg Oncol. 2016;114(5):587-596.

Expert Commentary

Margaret A. Tempero, MD

Director, Pancreas Center
Professor of Medicine
Division of Hematology and Oncology
UCSF
San Francisco, CA

With more effective treatment regimens available, there is an increasing interest in neoadjuvant therapy, especially in borderline resectable disease. But there is controversy about whether radiation should be included. Our group has published a retrospective series, showing excellent outcome, including pathologic complete response, with chemotherapy (FOLFIRINOX) alone. While it remains to be seen whether long-term survival is improved with this strategy, this concept is now being tested in several prospective randomized trials.

“Our group has published a retrospective series, showing excellent outcome, including pathologic complete response, with chemotherapy (FOLFIRINOX) alone in the neoadjuvant setting.”

Margaret A. Tempero, MD