Involved-Field Radiation Therapy for Patients With Unresectable Pancreatic Adenocarcinomas: Failure Pattern Analysis

Ricardo C Fogaroli; Douglas G Castro; Maria L Silva; Antonio Cassio A Pellizzon; Guilherme R Gondim; Michael J Chen; Henderson Ramos; Elson S Neto; Carolina H Abrahão

doi:10.7759/cureus.48106

Involved-Field Radiation Therapy for Patients With Unresectable Pancreatic Adenocarcinomas: Failure Pattern Analysis

Cureus. 2023 Nov 1;15(11):e48106. doi: 10.7759/cureus.48106. eCollection 2023 Nov.

Authors

Ricardo C Fogaroli¹, Douglas G Castro¹, Maria L Silva², Antonio Cassio A Pellizzon², Guilherme R Gondim², Michael J Chen², Henderson Ramos¹, Elson S Neto¹, Carolina H Abrahão¹

Affiliations

¹ Radiotherapy, A.C. Camargo Cancer Center, São Paulo, BRA.
² Radiation Oncology, A.C. Camargo Cancer Center, São Paulo, BRA.

Abstract

Introduction Unresectable pancreatic tumors are frequently diagnosed. Initial treatment is carried out with chemotherapy. Eventually, in selected cases, radiotherapy may be used to improve local control rates and relieve the symptoms. The volume of radiotherapy treatment fields is the subject of controversy in the literature. The use of involved fields with the gross tumor volume encompassing the primary tumor and lymph nodes considered clinically positive is associated with a lower rate of side effects, but can lead to a higher rate of regional loco failures, especially in regional lymph nodes. The purpose of this article is to analyze the failure pattern of chemotherapy and involved-field radiation therapy (IFRT) for treating patients with unresectable pancreatic adenocarcinomas. Methods Clinical records of thirty consecutive patients treated from March 2016 to June 2020 for unresectable pancreatic adenocarcinoma were analyzed. The patients were treated with initial systemic chemotherapy (median: 6 cycles) with regimens based on gemcitabine or oxaliplatin-irinotecan (folfirinox/folfox) followed by radiotherapy (total dose of 50-54 Gy/with fractionation of 2 Gy/day). The patients were treated with IFRT. Local failure (LF) was defined as an increase in radiographic abnormality within the planning target volume (PTV). Elective nodal failure (ENF) was defined as recurrence in any lymph node region outside the PTV. Any other failure was defined as distant failure (DF). Results The median age of the patients was 68 years (range: 44-80 years); 20 patients (66.7%) were men, and 11 (36.6%) and 19 (63.4%) patients presented with tumors of stage II and III, respectively. Most patients (63.3%) had tumors in the pancreatic head. The median survival was 17.2 months. Tumor recurrences were classified as LF, DF, LF and DF in 7 (23.3%), 17 (56.7%), and 5 (16.7%) patients, respectively. Only one patient (3.3%) had both LF and ENF. No severe side effects related to radiotherapy were reported. Conclusion The use of IFRT did not cause a significant amount of ENF, besides presenting low morbidity, which is of special importance for patients with locally advanced tumors or low performance status. The predominant failure pattern was distant metastases.

Keywords: distant metastases; failure patterns; involved-field irradiation; palliative radiation therapy; pancreatic-biliary cancer.