title: Adjuvant chemoradiation therapy for pancreatic adenocarcinoma: who really benefits?
abstract: BACKGROUND
  The role of adjuvant chemoradiation therapy (CRT) in pancreatic cancer remains controversial. The primary aim of this study was to determine if CRT improved survival in patients with resected pancreatic cancer in a large, multiinstitutional cohort of patients.
  
  
  METHODS
  Patients undergoing resection for pancreatic adenocarcinoma from seven academic medical institutions were included. Exclusion criteria included patients with T4 or M1 disease, R2 resection margin, preoperative therapy, chemotherapy alone, or if adjuvant therapy status was unknown.
  
  
  RESULTS
  There were 747 patients included in the initial evaluation. Primary analysis was performed between patients that had surgery alone (n=374) and those receiving adjuvant CRT (n=299). Median followup time was 12.2 months and 14.5 months for survivors. Median overall survival for patients receiving adjuvant CRT was significantly longer than for those undergoing operation alone (20.0 months versus 14.5 months, p=0.001). On subset and multivariate analysis, adjuvant CRT demonstrated a significant survival advantage only among patients who had lymph node (LN)-positive disease (hazard ratio 0.477, 95% CI 0.357 to 0.638) and not for LN-negative patients (hazard ratio 0.810, 95% CI 0.556 to 1.181). Disease-free survival in patients with LN-negative disease who received adjuvant CRT was significantly worse than in patients who had surgery alone (14.5 months versus 18.6 months, p=0.034).
  
  
  CONCLUSIONS
  This large multiinstitutional study emphasizes the importance of analyzing subsets of patients with pancreas adenocarcinoma who have LN metastasis. Benefit of adjuvant CRT is seen only in patients with LN-positive disease, regardless of resection margin status. CRT in patients with LN-negative disease may contribute to reduced disease-free survival.
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-6860, USA.
authors.forename: Nipun B
authors.initials: NB
authors.lastname: Merchant
authors.forename: Jennifer
authors.initials: J
authors.lastname: Rymer
authors.forename: Elizabeth A S
authors.initials: EA
authors.lastname: Koehler
authors.forename: G Daniel
authors.initials: GD
authors.lastname: Ayers
authors.forename: Jason
authors.initials: J
authors.lastname: Castellanos
authors.forename: David A
authors.initials: DA
authors.lastname: Kooby
authors.forename: Sharon H
authors.initials: SH
authors.lastname: Weber
authors.forename: Clifford S
authors.initials: CS
authors.lastname: Cho
authors.forename: C Max
authors.initials: CM
authors.lastname: Schmidt
authors.forename: Atilla
authors.initials: A
authors.lastname: Nakeeb
authors.forename: Jesus M
authors.initials: JM
authors.lastname: Matos
authors.forename: Charles R
authors.initials: CR
authors.lastname: Scoggins
authors.forename: Robert C G
authors.initials: RC
authors.lastname: Martin
authors.forename: Hong Jin
authors.initials: HJ
authors.lastname: Kim
authors.forename: Syed A
authors.initials: SA
authors.lastname: Ahmad
authors.forename: Carrie K
authors.initials: CK
authors.lastname: Chu
authors.forename: Rebecca
authors.initials: R
authors.lastname: McClaine
authors.forename: Brian K
authors.initials: BK
authors.lastname: Bednarski
authors.forename: Charles A
authors.initials: CA
authors.lastname: Staley
authors.forename: Kenneth
authors.initials: K
authors.lastname: Sharp
authors.forename: Alexander A
authors.initials: AA
authors.lastname: Parikh
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000368:Aged; D017024:Chemotherapy, Adjuvant; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016016:Proportional Hazards Models; D018714:Radiotherapy, Adjuvant; D016019:Survival Analysis