Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma

An outcomes trial

Authors

  • Harry Snady M.D., Ph.D.,

    Corresponding author
    1. Department of Medicine, Mt. Sinai Medical Center, New York, New York
    2. Pancreatobiliary Treatment Group, New York, New York
    3. Department of Medicine, St. Luke's-Roosevelt Hospital Center, New York, New York
    4. Department of Surgery, Community Hospital, Dobbs Ferry, New York
    5. EUS Imaging, New York, New York
    • EUS Imaging, Pancreatobiliary Treatment Group, 22 East 88th Street, New York, NY 10128
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  • Howard Bruckner M.D.,

    1. Department of Medicine, Mt. Sinai Medical Center, New York, New York
    2. Pancreatobiliary Treatment Group, New York, New York
    3. Department of Medicine, St. Luke's-Roosevelt Hospital Center, New York, New York
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  • Avram Cooperman M.D.,

    1. Pancreatobiliary Treatment Group, New York, New York
    2. Department of Surgery, Community Hospital, Dobbs Ferry, New York
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  • Jana Paradiso B.A.,

    1. Pancreatobiliary Treatment Group, New York, New York
    2. EUS Imaging, New York, New York
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  • Laurel Kiefer

    1. Pancreatobiliary Treatment Group, New York, New York
    2. EUS Imaging, New York, New York
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Abstract

BACKGROUND

Resection of pancreatic carcinoma is resource-intensive with a limited impact on survival. Chemotherapy and/or radiotherapy (RT) have been shown to be effective palliation. To examine whether preoperative chemoradiotherapy as the initial treatment improves survival for patients with a regional pancreatic adenocarcinoma with a minimal chance of being resected successfully, an outcomes trial was conducted.

METHODS

Patients with radiologically regional tumors were staged by laparotomy and/or computed tomography followed by endoscopic ultrasonography, angiography, and/or laparoscopy. Those with locally invasive, unresectable, regional pancreatic adenocarcinoma initially were treated with simultaneous split-course RT plus 5-fluorouracil, streptozotocin, and cisplatin (RT-FSP) followed by selective surgery (Group 1). Patients determined to have a resectable tumor initially underwent resection without preoperative chemoradiotherapy, with or without postoperative chemoradiotherapy (Group 2).

RESULTS

Over 8 years 159 patients presenting with nonmetastatic pancreatic adenocarcinoma were administered RT-FSP or underwent surgery for resection. Group 1, comprised of 68 patients initially treated with RT-FSP, had a 0% mortality rate within 30 days of entry. In 20 of 30 patients undergoing surgery after RT-FSP, tumors were downstaged and resected. Group 2, comprised of 91 patients who initially underwent successful resection, had a 5% mortality rate within 30 days of entry. Postoperatively, 63 of these patients received chemotherapy with or without RT. The median survival for Group 1 was 23.6 months compared with 14.0 months for Group 2 (P = 0.006) despite more advanced disease cases in Group 1. Survival favored RT-FSP regardless of whether lymph nodes were malignant. The dominant prognostic factor of earlier stage pancreatic carcinoma having an expected survival advantage was reversed by the initial nonoperative treatment.

CONCLUSIONS

Based on a reversal of the expected trend that patients with earlier stage resectable carcinoma (T1,2, N0,1, M0) who undergo removal of their tumors survive longer than patients with more advanced regional disease (T3, N0,1, M0), survival was found to improve significantly for patients reliably staged as having locally invasive, unresectable, nonmetastatic pancreatic adenocarcinoma when initially treated with RT-FSP. Cancer 2000;89:314–27. © 2000 American Cancer Society.

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