Radiation Therapy for Pancreas Cancer

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The role of radiation therapy in the treatment of pancreas cancer

Published in: Health & Medicine

Radiation Therapy for Pancreas Cancer

  1. 1. Radiation for Cancer of the Pancreas www.aboutcancer.com
  2. 2. rtog.org Radiation Therapy Oncology Group (RTOG)
  3. 3. NCCN.org National Comprehensive Cancer Network (NCCN)
  4. 4. Summary of Treatment 1.Resection is the only chance for a cure, and resectable patients show undergo surgery without delay followed by adjuvant therapy 2.Borderline resectable patients may benefit from neoadjuvant therapy and then surgery 3.Unresectable patients may benefit from chemotherapy or chemoradiation 4.Metastatic disease may benefit from chemotherapy or other palliative treatments
  5. 5. Survival Surgery offers the only cure, but only 10-20% are candidates and the 5 year survival is only 20% and median 13-20 months Locally advanced the median survival is 8-14 months Up to 60% already have metastases and survival of 4 to 6 months
  6. 6. Patterns of Failure after Surgery After surgery local relapse rate of 50 – 86% and distant recurrence rate of 40 – 90%
  7. 7. RTOG 9704 postOp FU then chemoradiation versus Gemcitabine then chemoradiation (50.4Gy) Slight advantage to the Gemzar arm for head of pancreas group: median survival of 20.5 months versus 17.1 months and long term 22%/5y versus 18%/5y
  8. 8. Is there a proven role for postOp radiation? • European studies (CONKO 001 Trial, EORTC Trial, ESPAC-1 showed benefit from chemotherapy but no benefit or in fact harm from including radiation and so they favor chemotherapy alone • American Trials (GITSG) showed benefit and favor including radiation
  9. 9. Benefits from Adjuvant Radiation GITSG postOp 40Gy + 5FU versus observation The radiation arm had better median survival (20 mos versus 11 mos) and 2 year survival 20% versus 10% EORTC postOp 5FU versus chemorad (40Gy in split course) and better 2Y survival in radiation arm: 34% versus 26% NCDB review chemoradiation improved survival (HR .784) but no chemoRx (1.08) Hopkins/ Mayo Clinic Review (Hsu, 2008) n = 1.045 Adjuvant 5FU/XRT improved survival from 16.3 months to 22.5 months
  10. 10. Adjuvant Radiotherapy and Chemotherapy for Pancreatic Carcinoma: The Mayo Clinic Experience (1975-2005) review 472 consecutive patients who underwent complete resection with negative margins (R0) for invasive carcinoma (T1-3N0- 1M0) Surgery S + Chemoradiation Overall survival 19.2 mos 25.2 mos Survival 39%/2y 50%/2y 15%/5y 28%/5y JCO July 20, 2008:3511-3516
  11. 11. Adjuvant Chemotherapy and Radiation Large, Prospectively Collected Database at the Johns Hopkins Hospital /The final cohort includes 616 patients. JCO July 20, 2008:3503-3510 Surgery S + Chemoradiation Median Survival 14.4 mos 21.2 mos Survival 31.9%/2y 43.9%/2y 15.4%/5y 20.1%/5y
  12. 12. Study number median 2y 5y GITSG chemoradiation 21 20.0 mos 42% 15% observation 22 10.9 mos 15% 5% chemoradiation 30 18.0 mos 46% 17% EORTC chemoradiation 110 21.6 mos 51% 25% observation 108 19.2 mos 41% 22% ESPAC-1 chemotherapy 147 20.1 mos 40% 21% no chemo 142 15.5 mos 30% 8% chemoradiation 145 15.9 mos 29% 10% no chemorad. 144 17.9 mos 41% 20% RTOG-9704 gemzar – chemorad 187 20.5 mos 31%/3 22% 5-FU – chemorad 201 17.2 mos 22%/3y 18% Prospective Trials of Adjuvant Therapy
  13. 13. RTOG 0848 Adjuvant Step 1: Adjuvant chemotherapy: (Arm1 Gemcitabine X 5 or Arm 2 Gemcitabine + Erlotinib X 5)) Step2: In no progression then: (Arm 3 one more cycle of chemo or Arm 2 1 cycle then chemoradiation with either capecitabine or 5-FU) Radiation dose is 1.8Gy X 28 (50.4Gy)
  14. 14. RTOG 0848 Adjuvant
  15. 15. NCCN Adjuvant
  16. 16. Summary of Treatment 1.Resection is the only chance for a cure, and resectable patients show undergo surgery without delay followed by adjuvant therapy 2.Borderline resectable patients may benefit from neoadjuvant therapy and then surgery 3.Unresectable patients may benefit from chemotherapy or chemoradiation 4.Metastatic disease may benefit from chemotherapy or other palliative treatments
  17. 17. Neoadjuvant Therapy (chemo or radiation prior to surgery) -About 1/3 of patients have a long delay after surgery getting started on PostOp therapy - 20-40% who get preOp will be found to develop Mets and avoid surgery -PreOp may increase the number of surgical candidates -No good randomized Trials -Some trials the 5 year survival in those undergoing a curative resection in the 32 – 36% range
  18. 18. SEER Data Base 3,885 Resectable Pancreas Cancer Treatment Number Median Survival Neoadjuvant XRT 70 (2%) 23 months PostOp XRT 1,478 (38%) 17 months Surgery Only 2,337 (60%) 12 months . Int J Radiat Oncol Biol Phys2008;72(4):1128–1133.
  19. 19. Summary of Treatment 1.Resection is the only chance for a cure, and resectable patients show undergo surgery without delay followed by adjuvant therapy 2.Borderline resectable patients may benefit from neoadjuvant therapy and then surgery 3.Unresectable patients may benefit from chemotherapy or chemoradiation 4.Metastatic disease may benefit from chemotherapy or other palliative treatments
  20. 20. Radiation for Unresectable Pancreas Cancer ECOG Trial, Loehrer 2011) Therapy Median Survival Gemzar 9.2 months Gemzar + Radiation 11.1 months Michigan Trial / IMRT 55Gy + Gemzar, Ben-Josef 2012 Therapy Survival Historical 11.2 months 13%/2y IMRT 14.8 months 30%/2y
  21. 21. Survival in ECOG Trial JCO November 1, 2011vol. 29 no. 31 4105-4112 Chemo + Radiation Chemo
  22. 22. Median Survival in Months Inoperable Pancreas Cancer Gemzar Alone 9.1 – 9.9 Gemzar + Radiation 11.3 – 11.9 JCO November 1, 2011vol. 29 no. 31 4105-4112
  23. 23. RTOG 1201 Unresectable Three Arms ChemoRx Radiation 1 gemcitabine X 12w 63Gy (IMRT) + capecitabine 2 gemcitabine X 12w 50.4Gy (3D) + capecitabine 3 FOLFIRINOX X 12w 50.4Gy (3D) + capecitabine IMRT Dose is 2.25Gy X 28 (63Gy) / 3D Dose is 1.8 Gy X 28 (50.4Gy) 95% of the PTV must get 95% of the prescribed dose and the Dmax to 0.03cc is no higher than 110% of the prescription dose
  24. 24. NCCN Inoperable
  25. 25. CT scan is obtained at the time of simulation CT images are then imported into the treatment planning computer
  26. 26. In the simulation process the CT and other images are used to create a computer plan
  27. 27. www.rtog.org
  28. 28. The CT Images Are Contoured and Labelled to Identify The Structures
  29. 29. Typical Radiation Fields
  30. 30. Radiation Fields
  31. 31. Computer Reconstruction from the CT Scan
  32. 32. Cancer Pancreas Liver Kidney Kidney Stomach Computer Reconstruction from the CT Scan
  33. 33. Computer Reconstruction from the CT Scan Lymph Nodes
  34. 34. Computer Reconstruction from the CT Scan Radiation Zone
  35. 35. Computer Reconstruction from the CT Scan Small Bowel Colon
  36. 36. Computer Reconstruction from the CT Scan Multiple structures (Liver, Stomach, Small Bowel, Colon, Spinal Cord, Kidneys) can all be effected by the radiation field
  37. 37. Pancreas Atlas for PostOp Radiation
  38. 38. PV – Portal Vein PJ – Pancreaticojejnosotomy SMA – Superior Mesenteric Artery CA – Celiac Artery
  39. 39. Computer Generated Radiation Targets
  40. 40. Radiation 1.Patients are usually treated daily, Monday through Friday for about 5 weeks 2.Dose of inoperable patients is 45- 54Gy (1.8 – 2.5Gy/fx) or 36Gy (2.4 fx) 3.PostOp patients 45-46Gy (1.8 – 2Gy/fx) with possible 5 – 9Gy boost
  41. 41. Normal Tissue Dose Limits
  42. 42. Normal Tissue Dose Limits
  43. 43. Side Effects of Pancreas Radiation
  44. 44. bowel kidneykidney stomach pancreas Side Effects of Pancreas Radiation liver
  45. 45. Side Effects of Pancreas Radiation • Fatigue • Loss of appetite • Diarrhea • Skin Irritation Long Term: Depending on the dose to other organs, there is a small risk of bowel damage or decreased function from the liver or kidneys
  46. 46. Radiation for Cancer of the Pancreas www.aboutcancer.com

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