title: Evolving concepts regarding the use of radiotherapy in the adjuvant management of periampullary pancreatic adenocarcinoma.
abstract: Presently, many oncologists feel that radiotherapy should not be part of curative intent, adjuvant management for pancreatic adenocarcinoma ("pancreatic cancer"). Historically, among oncologists who provided adjuvant therapy in this context, radiotherapy was included. This review examines the historical development of this controversy as well as (a) the history and principles of systemic and regional adjuvant therapy, (b) relevant nonsurgical studies using combined radiotherapy and chemotherapy for curative intent management of locally unresectable pancreatic cancer, (c) relevant results from surgical adjuvant studies using combined radiotherapy and chemotherapy for curative intent management of resected pancreatic cancer, and (d) results from phase III cooperative group studies of the adjuvant management of pancreatic cancer. Whether we conclude that adjuvant management should be used in a given clinical context depends on the disease and stage-specific results with surgery alone, risk of local and/or systemic failure, efficacy of chemotherapy and radiotherapy for addressing subclinical disease in this context, and the quality of data and studies available for making these assessments. In some settings where locoregional and systemic failure are codominant, both radiotherapy and chemotherapy are required for optimal results. For the adjuvant management of pancreatic cancer, many relevant studies with chemoradiotherapy have had serious limitations because they were nonrandomized, otherwise flawed in design and/or execution, inadequately stratified for currently known prognostic factors, or did not adequately consider radiotherapy technical details and quality assurance. As demonstrated in a secondary analysis of Radiation Therapy Oncology Group trial 9704, these factors are sufficiently powerful, when inadequately recognized and considered, to have obscured the potential therapeutic benefit of radiotherapy. Progress in pancreatic cancer has been hard to achieve. There are many indications that radiotherapy should be of benefit in the curative intent management of pancreatic cancer and we can ill afford to dismiss its use inappropriately. Therefore, well-designed, scientifically based, and appropriately executed phase III cooperative group studies aimed at providing improved clinical outcomes and addressing radiotherapy questions are both appropriate and necessary. Radiation Therapy Oncology Group trial 0848, currently accruing and ongoing, has been designed to clarify the role of radiotherapy in the adjuvant management of pancreatic cancer.
authors.affiliation: Department of Radiation Oncology, Rush University Medical Center, Chicago, IL 60612-3833, USA. Ross_A_Abrams@rush.edu
authors.forename: Ross Allen
authors.initials: RA
authors.lastname: Abrams
mesh_terms: D000230:Adenocarcinoma / Q000188:drug therapy / Q000532:radiotherapy* / Q000601:surgery; D000818:Animals; D017024:Chemotherapy, Adjuvant; D006801:Humans; D010190:Pancreatic Neoplasms / Q000188:drug therapy / Q000532:radiotherapy* / Q000601:surgery; D011379:Prognosis; D018714:Radiotherapy, Adjuvant