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Featured Case Studies 2004, Volume 1, Number 6

Recurrent Pancreatic Cancer: Dose Intensification for Local Control

by > David Grisell, DO

Clinical problem

After presenting in March 2002 with painless jaundice, this 71-year-old man underwent a Whipple procedure for a moderately differentiated adenocarcinoma of the pancreatic head. Standard adjuvant external radiation therapy (XRT) was administered to the pancreatic bed and regional nodes (to 50.4 Gy) with concurrent 5FU chemotherapy. The patient did well until February 2004 when rising levels of CA 19-9 serum tumor were detected. PET/CT restaging revealed a recurrent 2-3 cm mass that engulfed the porta hepatis and celiac axis, but no distant disease. Four cycles of Gemzar were administered. Although repeat CA 19-9 levels were further elevated, the mass appeared stable on repeat CT in May 2004. The patient sought a second opinion regarding salvage therapy for locally recurrent pancreatic cancer and a Karnofsky performance status of 80%.

Surgical resection of previously treated locally recurrent pancreatic cancer is essentially impossible. Extensive adhesion and fibrosis from previous surgical and radiation treatment prevents both adequate dissection and hemostasis. Additionally, re-irradiation and the additive dose of of previous irradiation poses a risk to the patient of a major to the surrounding bowel, nearby kidneys, and liver. Therefore, chemotherapy alone is the standard salvage regimen. However, we now have the capabilities not only to paint precise and accurate radiation does within 3D volumes but to mostly spare immediate adjacent normal structures. The advent of stereotactic localization techniques helps in the precise localization of a specific target to undergo a daily radiation therapy. When combined with intensity-modulated radiation therapy (IMRT), this regimen helps to avoid critical structures (kidneys, bowel, liver). Hyperfractionated radiation therapy (multiple small doses per day) can potentially further decrease the risk of major late toxicity (>6 months). With this technologically intensive strategy, re-irradiation is a feasible option.

Figure 1. A stereotactic radiotherapy treatment plan was developed to treat the tumor +1.5 cm margin (pink). Beam directions were selected to avoid the spinal cord (previously treated to tolerance) and minimize dose to the liver, kidney and bowels.

Comments

Although the patient most likely has incurable disease, several factors lend to further attempts at local control and long-term palliation if done relatively safely. These factors include the following: slow disease progression, relative long survival, and local-only recurrence. There is published data to support re-irradation in the head, neck, and pelvis, however, the retroperitoneum is just now being approached. Ultimately, the patient opted to pursue hyperfractionated re-irradiation with sensitizing chemotherapy.

• Machtay M, et al. Pilot study of postoperative reirradition, chemotherapy, and amifostine after surgical salvage for recurrent head-and-neck cancer. Int J Radiat Oncol Biol Phys 59:72-7, 2004.
• Mohiuddin M, et al. Long-term results of reirradiation for patients with recurrent rectal carcinoma. Cancer 95:1144-50, 2002.

How to refer

Because of the specific nature and complexity of the services we provide, patients must have a consultation with one of our physicians prior to being referred to the center. To schedule an appointment with one of our physicians, please contact Precision Radiotherapy at 513-475-7777.