title: Proton therapy with concomitant capecitabine for pancreatic and ampullary cancers is associated with a low incidence of gastrointestinal toxicity.
abstract: BACKGROUND
  To review treatment toxicity for patients with pancreatic and ampullary cancer treated with proton therapy at our institution.
  
  
  METHODS
  From March 2009 through April 2012, 22 patients were treated with proton therapy and concomitant capecitabine (1000 mg PO twice daily) for resected (n = 5); marginally resectable (n = 5); and unresectable/inoperable (n = 12) biopsy-proven pancreatic and ampullary adenocarcinoma. Two patients with unresectable disease were excluded from the analysis for reasons unrelated to treatment. Proton doses ranged from 50.40 cobalt gray equivalent (CGE) to 59.40 CGE.
  
  
  RESULTS
  Median follow-up for all patients was 11 (range 5-36) months. No patient demonstrated any grade 3 toxicity during treatment or during the follow-up period. Grade 2 gastrointestinal toxicities occurred in three patients, consisting of vomiting (n = 3); and diarrhea (n = 2). Median weight loss during treatment was 1.3 kg (1.75% of body weight). Chemotherapy was well-tolerated with a median 99% of the prescribed doses delivered. Percentage weight loss was reduced (p = 0.0390) and grade 2 gastrointestinal toxicity was eliminated (p = 0.0009) in patients treated with plans that avoided anterior and left lateral fields which were associated with reduced small bowel and gastric exposure.
  
  
  CONCLUSIONS
  Proton therapy may allow for significant sparing of the small bowel and stomach and is associated with a low rate of gastrointestinal toxicity. Although long-term follow-up will be needed to assess efficacy, we believe that the favorable toxicity profile associated with proton therapy may allow for radiotherapy dose escalation, chemotherapy intensification, and possibly increased acceptance of preoperative radiotherapy for patients with resectable or marginally resectable disease.
authors.affiliation: University of Florida Proton Therapy Institute, Jacksonville, Florida 32206, USA. rnichols@floridaproton.org
authors.forename: R Charles
authors.initials: RC
authors.lastname: Nichols
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: George
authors.forename: Robert A
authors.initials: RA
authors.lastname: Zaiden
authors.forename: Ziad T
authors.initials: ZT
authors.lastname: Awad
authors.forename: Horacio J
authors.initials: HJ
authors.lastname: Asbun
authors.forename: Soon
authors.initials: S
authors.lastname: Huh
authors.forename: Meng Wei
authors.initials: MW
authors.lastname: Ho
authors.forename: Nancy P
authors.initials: NP
authors.lastname: Mendenhall
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Morris
authors.forename: Bradford S
authors.initials: BS
authors.lastname: Hoppe
mesh_terms: D000230:Adenocarcinoma / Q000453:epidemiology / Q000473:pathology / Q000628:therapy*; D000284:Administration, Oral; D000368:Aged; D014670:Ampulla of Vater / Q000187:drug effects / Q000473:pathology / Q000528:radiation effects; D000069287:Capecitabine; D059248:Chemoradiotherapy / Q000009:adverse effects*; D003138:Common Bile Duct Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000628:therapy*; D003841:Deoxycytidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D004334:Drug Administration Schedule; D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology; D005260:Female; D005472:Fluorouracil / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D005767:Gastrointestinal Diseases / Q000453:epidemiology* / Q000209:etiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000628:therapy*; D061766:Proton Therapy / Q000009:adverse effects* / Q000379:methods; D011832:Radiation Injuries / Q000453:epidemiology; D011879:Radiotherapy Dosage; D012189:Retrospective Studies
chemical_list: D003841:Deoxycytidine; D000069287:Capecitabine; D005472:Fluorouracil