Top Line: Just when and how is radiation for pancreatic cancer delivered these days..?
The Study: Today we are delving into the recent case-based practical guideline for pancreas stereotactic body radiotherapy (SBRT) from the Radiosurgery Society. For decades radiotherapy for pancreatic cancer has been plagued by severe limitations on therapeutic doses by encompassing radiosensitive structures, not to mention an overwhelming competing risk for distant disease. But incredible advancements in the sophistication of radiotherapy delivery coupled with increasingly effective systemic therapy regimens continue to make this an intriguing therapeutic option. When it comes to borderline resectable cases, we’re all familiar with the Alliance trial that did nothing to rally radiation supporters. Here the authors point to, beyond obvious red flags with progression events in the radiation arm occuring before radiation, an on-trial lack of elective coverage of the “triangle” space (i.e., between the celiac artery, superior mesenteric artery, common hepatic artery, and portal vein/superior mesenteric vein) which has proven a critical locale for local recurrence. Table 2 summarizes their approach to pre-op SBRT for these cases with target volumes—including, you guessed it, the triangle space—motion management and prescriptions ranging up to 50 Gy in 5 fractions for favorable anatomy and/or with daily MRI-guided adaptive planning. Table 3 summarizes dose constraints, which are without exception prioritized over higher dose coverage recognizing you can always cover dicey areas with at least 25 Gy. For inoperable locally-advanced cases with no systemic disease after initial chemo, SBRT (or dose-escalated hypofractionated IMRT when tumor is involving bowel) is certainly reasonable. A final pearl is the recommendation for a daily PPI to start two weeks prior to radiation and to continue for 6-12 months after to minimize risk of ulceration.
TBL: File away this useful resource for planning your next high-dose ablative radiotherapy for inoperable pancreatic cancer with no distant disease after full-course initial systemic therapy. | Liu, Pract Radiat Oncol 2024
The Study: Today we are delving into the recent case-based practical guideline for pancreas stereotactic body radiotherapy (SBRT) from the Radiosurgery Society. For decades radiotherapy for pancreatic cancer has been plagued by severe limitations on therapeutic doses by encompassing radiosensitive structures, not to mention an overwhelming competing risk for distant disease. But incredible advancements in the sophistication of radiotherapy delivery coupled with increasingly effective systemic therapy regimens continue to make this an intriguing therapeutic option. When it comes to borderline resectable cases, we’re all familiar with the Alliance trial that did nothing to rally radiation supporters. Here the authors point to, beyond obvious red flags with progression events in the radiation arm occuring before radiation, an on-trial lack of elective coverage of the “triangle” space (i.e., between the celiac artery, superior mesenteric artery, common hepatic artery, and portal vein/superior mesenteric vein) which has proven a critical locale for local recurrence. Table 2 summarizes their approach to pre-op SBRT for these cases with target volumes—including, you guessed it, the triangle space—motion management and prescriptions ranging up to 50 Gy in 5 fractions for favorable anatomy and/or with daily MRI-guided adaptive planning. Table 3 summarizes dose constraints, which are without exception prioritized over higher dose coverage recognizing you can always cover dicey areas with at least 25 Gy. For inoperable locally-advanced cases with no systemic disease after initial chemo, SBRT (or dose-escalated hypofractionated IMRT when tumor is involving bowel) is certainly reasonable. A final pearl is the recommendation for a daily PPI to start two weeks prior to radiation and to continue for 6-12 months after to minimize risk of ulceration.
TBL: File away this useful resource for planning your next high-dose ablative radiotherapy for inoperable pancreatic cancer with no distant disease after full-course initial systemic therapy. | Liu, Pract Radiat Oncol 2024