Top Line: How should we contour targets for pancreatic cancer—tight margins or elective coverage of neural and nodal pathways?
The Study: This comprehensive review dissects the messy history of target volume delineation in pancreas trials where variation in contouring has fueled inconsistent outcomes. Emerging data highlight that gross tumor coverage isn’t enough. Extra-pancreatic perineural invasion (PNI) is nearly universal and a major driver of locoregional failure, often more so than lymph nodes. Trials like Alliance A021501 used tight margins, but others (PREOPANC, MGH, Cincinnati) tested broader or anatomically-defined elective coverage, showing hints of improved locoregional control. Hopkins data with preop SBRT reinforced that R0 resections don’t guarantee durable control, and failures often occur along un-irradiated neural tracts.
TBL: Anatomically-informed elective coverage of perineural pathways (celiac, SMA, CHA plexi, etc.) could prove the key to improving locoregional control in pancreatic cancer radiation. | Narang, Semin Radiat Oncol 2025
The Study: This comprehensive review dissects the messy history of target volume delineation in pancreas trials where variation in contouring has fueled inconsistent outcomes. Emerging data highlight that gross tumor coverage isn’t enough. Extra-pancreatic perineural invasion (PNI) is nearly universal and a major driver of locoregional failure, often more so than lymph nodes. Trials like Alliance A021501 used tight margins, but others (PREOPANC, MGH, Cincinnati) tested broader or anatomically-defined elective coverage, showing hints of improved locoregional control. Hopkins data with preop SBRT reinforced that R0 resections don’t guarantee durable control, and failures often occur along un-irradiated neural tracts.
TBL: Anatomically-informed elective coverage of perineural pathways (celiac, SMA, CHA plexi, etc.) could prove the key to improving locoregional control in pancreatic cancer radiation. | Narang, Semin Radiat Oncol 2025