Elective nodal irradiation for unresected pancreatic head cancer?

[seper]

What is the current thinking for treating clinically negative 1st echelon LN's for patients receiving chemo-RT? No prior surgery, the tumor remains in place (T3 or T4). Induction systemic chemo was given.

A couple of reasonable treatment options:
a) treat wide nodal field to 45 Gy with conedown to the primary - the old way.
b) treat just the primary with a tight margin - isolated nodal failures are rare.
c) what I've seen people do is a compromise - treat "peripancreatic area" to about 45 Gy while simultaneously boosting the primary via IMRT.

Any comments appreciated

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[karlranck]

I think it often depends on what type of chemotherapy is being given...i.e. with 5FU, more conventional larger fields are often used vs. with Gemzar, only GTV + margin is likely to be covered due to a concern for acute toxicity. Interestingly, there is an asian randomized trial of 5FU and Gemzar with elective nodal irradiation that did not show an increase in acute toxicity, but I think most are sufficiently worried about Gemzar to reduce the radiation treatment volumes.

 

[Palex80]

I think this is a case-by-case discussion.
I would generally never go for option a).
I may go for option b) in patients who have not responded all that well to induction chemo and are not in an excellent performance status. Delivering RT in these patients does not have any realistic curative chance, therefore you should try to limit toxicities as far as you can. We usually treat these patients only on the GTV+1.5 cm margin with 12-13 x 3Gy parallel to 5FU.
Option c) is interesting for patients who have responded well to chemo and have a good performace status. You can safely treat with 45 Gy to a larger field (but don't overdue it!) and then go down only to the primary. How you cone down is a matter of "taste". We sometimes use SBRT in these cases or else just do IMRT.
Europe is a place were you rarely treat pancreatic cancer with RT, so I can only report from limited experience of around 6-8 patients/year in our institution.
The French GERCOR study used standard "old-style" fields, so I think that a lot of confusion results from the published evidence, which does not reflect common practice IMHO.
http://jco.ascopubs.org/content/25/3/326.short

 

[deleted4401]

Unresectable pancreatic cancer is an incurable disease. I think GTV plus margin is becoming standard. I like the big fractions, too, but do something like 2.5 Gy x 10, take a break, then take it to 40ish.

I don't get Stanford's outcomes with SBRT - their local control is in the 90 percent range. At UPMC we have the largest data set and we had nowhere near that control rate. But, the survival was comparable to CRT in terms of survival, so I think if you can get it covered, a single shot of 20 Gy and then on to Gem/hospice is a good strategy.

 

[medgator]

Unresectable pancreatic cancer is an incurable disease. I think GTV plus margin is becoming standard .

Yep. Pretty similar logic to how most abandoned ENI for lung cancer.

In the post op setting though, people still do it

 

[seper]

Thank you all - agree with all remarks (except for comparing stage III NSCLC and unresectable pancreatic ca).

How about preoperative chemoradiation for marginally resectable, clinically node-negative pancreatic head cancer? In that situation, the highest risk nodal regions must be prophylactically treated. What are the fields?

 

[deleted4401]

Thank you all - agree with all remarks (except for comparing stage III NSCLC and unresectable pancreatic ca).

How about preoperative chemoradiation for marginally resectable, clinically node-negative pancreatic head cancer? In that situation, the highest risk nodal regions must be prophylactically treated. What are the fields?

Not true. A lot of the preop protocols only treat gross disease. Many do 30 - 36 Gy in big fractions (UPMC, MDACC) to the gross disease. They tolerate it really well, too. I don't get it really, though, they almost never shrink, but I guess maybe some change enough to make a difference for the surgery.

 

[Reaganite]

Christopher Crane's ASTRO Refresher GI lecture from 2009 (or 08..can't remember) covers these issues nicely. Would highly recommend it. He was quite adamant about GTV only + margin for unresectable or marginally resectable.

 

[seper]

Just be aware that groups other than MDA (Moffitt, Harvard) are reporting use of ENI for all marginally respectable patients. For example, PMID: 22020923.

 

[mikedc813]

Yes, our protocol here for borderline resectable patients has now shifted to one of neoadjuvant GTX chemo followed by 5 fraction SBRT, including only the tumor and dose painting the area of vessel abutment to a higher dose. We have had very good results with very minimal toxicity. A large percentage of patients who ended up going to Whipple who were clinically N+ actually were found to be pathologically N- despite not intentionally irradiating the nodes.

 

[Palex80]

Yes, our protocol here for borderline resectable patients has now shifted to one of neoadjuvant GTX chemo followed by 5 fraction SBRT, including only the tumor and dose painting the area of vessel abutment to a higher dose. We have had very good results with very minimal toxicity. A large percentage of patients who ended up going to Whipple who were clinically N+ actually were found to be pathologically N- despite not intentionally irradiating the nodes.

How soon after SBRT are the patients being operated?

 

[mikedc813]

Generally restaging at 4 weeks and surgery at 6 if there's evidence of a clear plane between the tumor and vasculature.

 

[Haybrant]

reviving a old thread on this. 60 yo man ok performance status unresected pancreatic adeno with poor response to first line chemo. Plan is concurrent RT + 5FU. Primary tumor is large like 5 cm and there are scattered peripancreatic nodes up to 1.5 cm max. Do you cover the nodes and the primary + a margin. In covering the nodes it ends up being a reasonable sized volume. Plan was for 5040, are people using different schedules? Thank you

 

[seper]

5 years more into practice from the beginning of this thread, now I know this is pure palliation. I'd do 50/25 to all GTV + tight margin

 

[medgator]

5 years more into practice from the beginning of this thread, now I know this is pure palliation. I'd do 50/25 to all GTV + tight margin

I try to push 54-55.8 to primary tumor. I got one guy out 2+ years with that per one of my med oncs who I spoke with recently. But certainly a rare case

 

[seper]

The fact that 1st line of therapy failed, makes me think that prognosis is especially poor. That 1% that survive, they are the ones that respond well to 1st line treatment.

 

[evilbooyaa]

I try to push 54-55.8 to primary tumor. I got one guy out 2+ years with that per one of my med oncs who I spoke with recently. But certainly a rare case

If you look at Chris Crane's responses on mednet, you'll see the recommendation for BED > 100 with his hypofractionated regimens using stereotactic technique. Anybody considering doing that or is that only a MDA/MSKCC Ivory Tower regimen? No power to make attendings consider it, but not sure if others on this board have.

 

[Palex80]

It's a trade off between toxicity and local control. If you believe local control is necessary, do it. If not, don't. Haybrant's patient did not respond all that well to systemic treatment. He will likely die of systemic disease. so pushing for maximum local control may not be right approach. This is a bit like Stage III NSCLC (to revive the dispute we had 6 years ago...).

 

[seper]

Yes, we totally need a phase III study of dose escalation for pancreatic cancer. I doubt that Care believes in dose escalation himself. He talks about need to identify a subset of patients that would benefit from dose escalation using molecular markers.

If you look at Chris Crane's responses on mednet, you'll see the recommendation for BED > 100 with his hypofractionated regimens using stereotactic technique. Anybody considering doing that or is that only a MDA/MSKCC Ivory Tower regimen? No power to make attendings consider it, but not sure if others on this board have.

 

[medgator]

If you look at Chris Crane's responses on mednet, you'll see the recommendation for BED > 100 with his hypofractionated regimens using stereotactic technique. Anybody considering doing that or is that only a MDA/MSKCC Ivory Tower regimen? No power to make attendings consider it, but not sure if others on this board have.

not doing that in pp, not worth the risk imo

 

[BobbyHeenan]

If you look at Chris Crane's responses on mednet, you'll see the recommendation for BED > 100 with his hypofractionated regimens using stereotactic technique. Anybody considering doing that or is that only a MDA/MSKCC Ivory Tower regimen? No power to make attendings consider it, but not sure if others on this board have.

I have used this technique (hypofrac, stereotactic, high BED) approach for intrahepatic cholangio. The Crane/JCO paper is really great with the supplement outlining their technique, contouring, DVH goals, etc and really helps guide treatment. Have had good experience with a couple of patients treated this way. I am reluctant to do some ivory tower things I saw/did at the academic center, but for this particular technique I have felt comfortable, largely because of how well the paper(s) were written. I specifically cite them in my consult note, treatment planning note, etc, because to some degree it is "risky" to treat in this manner...though let's be honest, not a whole lot of great options for unresectable cholangio or pancreatic cancer. With intrahepatic cholangio they are using some pretty high doses, but in the supplement it talks about they started their experience at slightly lower doses like 55 Gy in 15 fractions...so you can always consider starting at this "lower" dose and working up based on you and patient comfort.

However, I haven't done this high dose hypofract technique for pancreas. There has been a big push at our cancer center for intensifying chemo for unresectable patients rather than radiation.

 

[evilbooyaa]

Appreciate the responses. For the record, I would consider it something to consider in the stable disease after 5 cycles of chemo setting. I don't know if I'm just drinking the Chris Crane Kool-Aid, but to me it makes sense to try something for this group of patients.

 

[Neuronix]

reviving a old thread on this. 60 yo man ok performance status unresected pancreatic adeno with poor response to first line chemo. Plan is concurrent RT + 5FU. Primary tumor is large like 5 cm and there are scattered peripancreatic nodes up to 1.5 cm max. Do you cover the nodes and the primary + a margin. In covering the nodes it ends up being a reasonable sized volume. Plan was for 5040, are people using different schedules? Thank you

I typically do 5 fraction SBRT up to 50 Gy with reduction of dose depending on organ at risk doses (typically duodenum, sometimes stomach). Chemo is sequential.

I only treat the primary and maybe some gross nodes right next to the primary in these situations. I certainly don't treat elective and I don't reach to get all of the other suspicious or involved nodes.

When doing conventionally fractionated per RTOG 0848, I've been able to meet protocol constraints at 50.4 Gy. I consider this when the tumor is too large to treat safely with SBRT (such as the 5 cm primary case). Could also consider 30 Gy in 10 fractions as always for poor performance status or life expectancy.

 

[OTN]

If you look at Chris Crane's responses on mednet, you'll see the recommendation for BED > 100 with his hypofractionated regimens using stereotactic technique. Anybody considering doing that or is that only a MDA/MSKCC Ivory Tower regimen? No power to make attendings consider it, but not sure if others on this board have.

I've been doing it, especially for unresectable intrahepatic cholangiocarcinomas and have been very, very happy with the results. I treated someone he knew very well with that regimen, and he was really helpful in walking me through everything start to finish. As a result, I have a ton of confidence in his technique and VERY much drink the Kool-Aid. MDA's driving him away to MSKCC was a huge, huge loss for them.

 

[nkmiami]

What Chris Crane is saying makes all the sense in the world, and have used the dosing scheme in liver, but not the head of the pancreas. I have given 6.6 x 5 with stereo, and no one has done well, which makes sense as this is not really very much radiation.
Maybe be placing a marker and calling it "stereo," I expected something magical to happen.

In cervix, 6 gy x 5 with HDR brachy is considered the equivalent of 40 Gy/ ldr/external beam. Also, a significant amount of locally advanced tumors at resection have duodenal extension, which is often not covered in stereotactic treatments.

 

[thecarbonionangle]

Until improves, going to be tough to make much inroads, IMO