What are the indications for radiotherapy in pancreatic cancer?

From the Guidelines

Radiotherapy is indicated for pancreatic cancer in several clinical scenarios, including locally advanced unresectable disease, as neoadjuvant therapy to downstage borderline resectable tumors, and as adjuvant treatment following surgical resection, particularly when positive margins or lymph node involvement are present. The indications for radiotherapy in pancreatic cancer can be summarized as follows:

• Locally advanced unresectable disease: radiotherapy can be used to control local disease and reduce symptoms
• Borderline resectable tumors: neoadjuvant radiotherapy can be used to downstage the tumor and increase the chances of successful surgical resection
• Adjuvant treatment: radiotherapy can be used after surgical resection to reduce the risk of local recurrence, particularly in patients with positive margins or lymph node involvement Some key points to consider when using radiotherapy for pancreatic cancer include:
• The use of external beam radiation therapy (EBRT) or stereotactic body radiation therapy (SBRT)
• The importance of careful treatment planning, including CT simulation and delineation of critical structures
• The potential benefits of concurrent chemotherapy, such as gemcitabine or capecitabine
• The need to balance the potential benefits of radiotherapy with the potential risks and side effects, such as fatigue, nausea, and diarrhea 1. In terms of specific treatment regimens, a typical approach might include EBRT delivering 45-54 Gy in 1.8-2.0 Gy daily fractions over 5-6 weeks, often combined with concurrent chemotherapy such as gemcitabine (1000 mg/m² weekly) or capecitabine (825-1000 mg/m² twice daily on radiation days) 1. It's worth noting that the optimal approach to radiotherapy for pancreatic cancer is still an area of ongoing research and debate, and the best approach may vary depending on individual patient factors and the specific clinical scenario 1.

From the Research

Indications of Radiotherapy in Pancreas Cancer

The indications of radiotherapy in pancreas cancer are varied and depend on the stage and resectability of the tumor. Some of the key indications include:

• Neoadjuvant chemoradiotherapy (CRT) to downstage borderline resectable disease and make resection possible, which could translate to a survival benefit 2
• Adjuvant CRT for patients with incompletely resected tumors (R1) to improve survival 3
• Definitive chemoradiotherapy for patients with locally advanced tumors who are not candidates for surgery 2, 3
• Palliative radiotherapy to relieve symptoms such as pain and bleeding in patients with advanced disease 4

Settings for Radiotherapy

Radiotherapy can be used in various settings for pancreas cancer, including:

• Neoadjuvant setting: to downstage the tumor and make it resectable 2, 3
• Adjuvant setting: to eliminate any remaining cancer cells after surgery and reduce the risk of recurrence 2, 3
• Definitive setting: as a primary treatment for patients with locally advanced tumors who are not candidates for surgery 2, 3
• Palliative setting: to relieve symptoms and improve quality of life in patients with advanced disease 4

Techniques and Modalities

Various radiotherapy techniques and modalities can be used to treat pancreas cancer, including:

• Intensity-modulated radiation therapy (IMRT) to reduce doses to organs at risk and improve tolerance 3, 5
• Stereotactic body radiation therapy (SBRT) as a neoadjuvant or exclusive treatment 3, 5
• Magnetic resonance-guided radiation therapy to improve accuracy and reduce toxicity 5
• Particle therapy to improve outcomes and reduce side effects 5