Intraoperative Irradiation by Leonard L. Gunderson Christopher G. Willett Felipe A. Calvo & Louis B. Harrison

Author:Leonard L. Gunderson, Christopher G. Willett, Felipe A. Calvo & Louis B. Harrison
Language: eng
Format: epub
Publisher: Humana Press, Totowa, NJ

Conclusions and Future Possibilities

Long-term survival and disease control are achievable in select patients with borderline resectable or locally unresectable pancreas cancer, and survival appears to be better in patients with resection after full-dose preop chemoradiation. Accordingly, continued evaluation of curative-intent combined modality therapy is warranted in this high-risk population of patients. However, additional strategies are needed to improve both resectability rates after preop chemoradiation and disease control (local and distant).

IORT, as part of a multimodality treatment plan for pancreas cancer, either locally advanced and unresectable or resectable, has the potential to increase local control at the site of the primary tumor without a significant increase in treatment toxicity risk. Currently, the high risk of systemic failure outweighs risks of local and regional failure in determining patient mortality. For unresectable tumors, an upfront course of induction chemotherapy may identify the 20–30% of patients who experience early distant progression, allowing for EBRT and/or IORT in those with disease less inclined to systemic progression [71]. With advances in the ability of systemic therapy to treat occult systemic metastases, the importance of maintaining good long-term local and regional control may take preference. Strategies to select appropriate patients for aggressive local therapy in the resectable, borderline resectable, or unresectable settings will advance through improvements in imaging, biomarkers, and genetics or through the timing of when to administer IORT and/or resection.

The incidence of abdominal relapse must be decreased by utilizing either more aggressive or new regimens of systemic or regional therapy (intrahepatic and intraperitoneal). Targeted therapies (i.e., epidermal growth factor receptor [EGFR] inhibitors, vascular endothelial growth factor [VEGF] inhibitors) and pancreas cancer vaccines are also being evaluated in an attempt to improve systemic disease control. As improvements are being made in distant disease control, the benefit of improved local control with IORT-containing regimens may become even more apparent.

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