title: Tolerability and Long-term Outcomes of Dose-Painted Neoadjuvant Chemoradiation to Regions of Vessel Involvement in Borderline or Locally Advanced Pancreatic Cancer.
abstract: We reviewed our experience involving patients with borderline resectable or locally advanced pancreatic cancer, treated with the dose-painted (DP) boost technique to regions of vessel involvement which preclude upfront surgical resection. We evaluated patient outcomes with respect to tolerability and treatment outcomes.
  
  
  
  We retrospectively reviewed 99 patients with borderline resectable (n=25) or locally advanced pancreatic cancer (n=74) treated with DP-neoadjuvant chemoradiation from 2010 to 2015. Tumor and regional lymph nodes were prescribed 50.4 Gy and the region around the involved blood vessel was boosted to 58.8 Gy in 28 fractions. The primary outcome was acute toxicity and late duodenal toxicity. Secondary outcomes included conversion to surgical resectability, local failure, disease-free survival, and overall survival (OS). Cox proportional hazards models were performed to evaluate for predictors of survival.
  
  
  
  All but 1 patient completed chemoradiation. The rates of grade 2+ and 3+ nausea were 40% and 12%, respectively. With regards to late toxicity, 5 patients developed potential RT-related grade 3+ duodenal complications including duodenal ulceration/bleeding (n=3) and duodenal stricture (n=2). With a median follow-up of 15 months, the median OS was 18.1 months. Among 99 patients in our study, 37 patients underwent surgical resection. For patients who underwent surgical resection (n=37), the median OS was 30.9 months. On multivariate analysis, only normalization of CA 19-9 post-RT was associated with improved OS.
  
  
  
  We found that DP-neoadjuvant chemoradiation to regions of vessel involvement is both feasible and well tolerated. In addition, we demonstrated that over one third of patients with initially deemed unresectable disease were able to undergo surgical resection after receiving neoadjuvant therapy including DP-chemoradiation.
authors.affiliation: Departments of Radiation Oncology.
authors.forename: Jennifer Y
authors.initials: JY
authors.lastname: Wo
authors.affiliation: Departments of Radiation Oncology.
authors.forename: Andrzej
authors.initials: A
authors.lastname: Niemierko
authors.affiliation: Medical Oncology.
authors.forename: David P
authors.initials: DP
authors.lastname: Ryan
authors.affiliation: Medical Oncology.
authors.forename: Lawrence S
authors.initials: LS
authors.lastname: Blaszkowsky
authors.affiliation: Medical Oncology.
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Clark
authors.affiliation: Medical Oncology.
authors.forename: Eunice L
authors.initials: EL
authors.lastname: Kwak
authors.affiliation: General Surgery, Massachusetts General Hospital, Boston, MA.
authors.forename: Keith D
authors.initials: KD
authors.lastname: Lillemoe
authors.affiliation: Departments of Radiation Oncology.
authors.forename: Lorraine N
authors.initials: LN
authors.lastname: Drapek
authors.affiliation: Medical Oncology.
authors.forename: Andrew X
authors.initials: AX
authors.lastname: Zhu
authors.affiliation: Medical Oncology.
authors.forename: Jill N
authors.initials: JN
authors.lastname: Allen
authors.affiliation: Medical Oncology.
authors.forename: Jason E
authors.initials: JE
authors.lastname: Faris
authors.affiliation: Medical Oncology.
authors.forename: Janet E
authors.initials: JE
authors.lastname: Murphy
authors.affiliation: Medical Oncology.
authors.forename: Ryan
authors.initials: R
authors.lastname: Nipp
authors.affiliation: General Surgery, Massachusetts General Hospital, Boston, MA.
authors.forename: Carlos
authors.initials: C
authors.lastname: Fernandez-Del Castillo
authors.affiliation: General Surgery, Massachusetts General Hospital, Boston, MA.
authors.forename: Cristina R
authors.initials: CR
authors.lastname: Ferrone
authors.affiliation: Departments of Radiation Oncology.
authors.forename: Theodore S
authors.initials: TS
authors.lastname: Hong
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001808:Blood Vessels / Q000473:pathology*; D059186:Chemoradiotherapy, Adjuvant / Q000401:mortality*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000401:mortality*; D009364:Neoplasm Recurrence, Local / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D010190:Pancreatic Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate