Efficacy of preoperative radiochemotherapy in patients with locally advanced pancreatic carcinoma

Background. The optimal care for patients with unresectable, non-metastatic pancreatic adenocarcinoma (PAC) is debated. We treated 17 consecutive cases with preoperative radiochemotherapy ( RCT) as a means for downstaging their tumours and compared outcome with 35 patients undergoing direct surgery for primarily resectable PAC during the same time period. Methods. The patients had biopsy proven, unresectable, non-metastatic PAC which engaged >= 50% of the circumference of a patent mesenteric/portal vein for a distance >= 2 cm and/ or < 50% of the circumference of a central artery for < 2 cm. The preop therapy included two courses of Xelox ( oxaliplatin 130 mg/m(2) d1; capecitabine 2 000 mg/m(2) d1 - 14 q 3 w) followed by 3-D conformal radiotherapy ( 50.4 Gy; 1.8 Gy fractions) with reduced Xelox ( d1-5 q 1 w X 6). Results. No incident of RCT-related CTC Grade 3 - 4 haematologic and six cases of non-haematologic side-effects were diagnosed. Sixteen patients completed the RCT and were rescanned with CT and reevaluated for surgery 4 weeks post-RCT. Five cases were diagnosed with new metastases to the liver. Eleven patients were accepted for surgery whereof eight underwent a curative R-0-resection. The median overall survival for the latter group was 29 months, which compared favourably with our control group of patients undergoing direct curative surgery for primarily resectable PAC ( median OS: 16 months; R-O-rate: 75%). Perioperative morbidity was similar in the two cohorts but the duration of surgery was longer ( 576 vs. 477 min) and the op blood loss was greater ( 3288 vs. 1460 ml) in the RCT-cohort ( p<0.05). The 30-day mortality was zero in both groups. Conclusion. Preoperative RCT in patients with locally advanced PAC resulted in a high rate of curative resections and promising median survival in our treatment series. This trimodality approach merits further exploration in new studies, which are currently underway at our Department.