Lines drawn.

Top Line: So what is everyone doing these days for borderline resectable pancreatic cancer (BRPC)?

The Studies: Most likely systemic therapy, but then what? Conventionally fractionated chemoradiation? Hypofractionated chemoradiation? SBRT? Thankfully ASTRO has new guidelines out for pancreas radiation. When it comes to BRPC, recs are to consider conventional chemoradiation or SBRT after chemo as part of a total neoadjuvant therapy approach. Here we have a small trial (n=25) from Michigan where patients with BRPC received 6 cycles of FOLFIRINOX followed by chemoradiation. The radiation target was gross disease with a 5 mm CTV margin treated to 2 Gy x 25 = 50 Gy + gem, and half went for resection—all margin negative (R0). In comparison, roughly two-thirds in the PREOPANC-1 and MGH trials went on to R0 resection. As a reminder, PREOPANC-1 actually showed improved overall survival with neoadjuvant 2.4 Gy x 15 = 36 Gy + gem. The MGH trial, on the other hand, used a hybrid short-course/conventional radiation approach depending on vascular involvement. Keep in mind, some people weren’t on the aforementioned guideline panel. What might they say? They might ask: What are we doing with BRPC in the first place? There’s nothing magical about “low-dose palliative SBRT” compared to conventional radiation. The real goal is to help get the patient to an R0 resection. In addition, there are concerns that the narrow margins used in the pre-operative setting could lead to high marginal failure rates. If you really wanna do some damage, ablate (with something more like 4.5 Gy x 15 = 67.5 Gy). Granted, if your surgeons and med-oncs expect an expedited course, a short 2 week regimen (of something like 3 Gy x 10-12 = 30-36 Gy) with wider margins might be preferred.

TBL: When it comes to borderline resectable pancreatic cancer, the bottom line is careful patient selection, chemo, and radiation to give patients the best chance at R0 resection. | Palta, Pract Radiat Oncol 2019 and Tran, Int J Radiat Oncol Biol Phys 2019