Locally advanced unresectable pancreatic carcinoma

[Kroll2013]

56 years old patient , poor PS that presented for an unresectable obstructing head of the pancreas carcinoma.
A biliary stent was placed. He received 6 FOLFIRINOX, with a good response. The tumor decreased in size, no metastases, but still not resectable. ( Poor PS , not even a candidate for surgery).

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[Gfunk6]

Well you have two options:

1. SBRT - would recommend five fractions to minimize risk of duodenal toxicity. Dosing is as high as you dare based on institutional experience and hardware. Personally I start at 7-8 Gy x5 and dial down from there.

2. CRT - 5FU with XRT to 50-54 Gy

Either approach would surely improve PFS and probably QoL but questionable OS benefit


Sent from my iPhone using SDN

 

[evilbooyaa]

I like Chris Crane's answers on mednet in regards to 75/25 or 67.5/15 but have never done it and don't know if it can be done well outside confines of MDA/MSKCC.

No difference in OS per LAP-07 (albeit this case has FOLFIRINOX and not Gem +/- Erlotinib). Can justify treating with either regimen Gfunk mentioned.

Honestly if he already has poor PS you're only going to make it worse with RT. If he's poor PS b/c of FOLFIRINOX x 6, then maybe an intense chemo holiday will help. You can either radiate or not radiate and you'll be right.

 

[emt409]

What is making unresectable? Vessel invasion? If it's vessel invasion, you can be conservative to the dose limiting areas of the tumor (e.g. 33/5 or 35/5, and try and dose escalate the tumor/vessel interface to 40 or even 45).

We use EUS-placed fiducials for triggered imaging, and daily CBCT. If the stent is still well positioned, you can use it as fiducial. You can have patient drink some watered down omnipaque or gastroview about 10-15 minutes (on empty stomach, takes longer if they ate recently) prior to setup to better visualize pancreaticoduodenal interface. We are still working on optimum dilution.

I would ask myself if I thought my traetment could make him resectable, if so, be more aggressive. If not, then aggressively palliate the obstructive mass, because that is what will kill him, but don't risk causing a GI bleed that will kill him before the tumor does.

 

[OTN]

I would favor 5-fraction SBRT. Regional nodal disease isn't an issue in his case, and his head-of-pancreas mass could cause problems if not controlled locally.

I have used Chris Crane's 75 in 25 / 67.5 in 15 regimen on a fair number of unresectable cholangiocarcinomas and central HCCs, and I've been very, very happy with the results. It's certainly doable outside of MDACC/MSKCC if you can do SBRT. In this situation, however, we do have a bit more data favoring a 5-fraction course.

No one would fault you for doing standard chemoRT as well, but my personal preference would be SBRT. Dosing is going to be limited by the duodenum, which you have to be very, very careful with.

 

[Palex80]

Well you have some very brave (our stupid) medical oncologists that decided to give a poor-PS patient "not even a candidate for surgery" 6 cycles of FOLFIRINOX... You stated that he was poor PS upon presentation, so I presume his PS is not the result of FOLFIRINOX.


Anyways, I do not think you can cure this patient (or pretty much any pancreatic cancer patient) with RT.

You can either treat now or wait until he develops progression and then treat if the progression is local or symptomatic.

I would give him a short course treatment, something like 36 / 3 or 39.9 / 2.66. You can combine it with capecitabine or moderately dose gemcitabine if you want to, but I wouldn't push for it.

 

[nkmiami]

Will be provocative here-I second Chris cranes approach. I dont think the data is very good for low dose,stereo-in -name -only-fractionations like 33/5. Chris Crane has data showing something like 20% long term survivors (without surgery) with his approach and I am not aware of any data like this with faux stero regimens.

 

[neo87]

I third the 75/25 SIB dosing, although I am a little more generous with the PRV around bowel than what I remember from those papers, and for that reason have to drop the dose sometimes depending on tumor location ...i agree with OTN that this is not difficult to do if you have experience with pancreas SBRT. I use this technique for ECOG 0-1 and will do 33/5 if they are ECOG 2.

 

[thecarbonionangle]

30/10 call it a day, 36/12 if you want

 

[Boston Red]

I third the 75/25 SIB dosing, although I am a little more generous with the PRV around bowel than what I remember from those papers, and for that reason have to drop the dose sometimes depending on tumor location ...i agree with OTN that this is not difficult to do if you have experience with pancreas SBRT. I use this technique for ECOG 0-1 and will do 33/5 if they are ECOG 2.

I have toyed with this before, but not pulled the trigger yet. Do you do daily CBCT sign off at the machine (like SBRT)? Or at the end of day? It seems very labor intensive to do this at the machine every day, but with these doses, you can't miss. Or do you figure that 25fx allows some forgiveness?

 

[neo87]

I have toyed with this before, but not pulled the trigger yet. Do you do daily CBCT sign off at the machine (like SBRT)? Or at the end of day? It seems very labor intensive to do this at the machine every day, but with these doses, you can't miss. Or do you figure that 25fx allows some forgiveness?

I do CBCT review at the machine for the first three fractions, and at that time reinforce very clearly with the therapists what I want them to call me to the machine for - this has worked well for me because I have great therapists. I am not sure what others are doing w/r/t supervision but would love to hear.

 

[nkmiami]

I do CBCT review at the machine for the first three fractions, and at that time reinforce very clearly with the therapists what I want them to call me to the machine for - this has worked well for me because I have great therapists. I am not sure what others are doing w/r/t supervision but would love to hear.

Like you, I also put a good margin on the prv. I use fiducials and a compression belt on these pts and am at machine for first several treatments. Try to define bowel, tumor on 50% phase, and line up to 50% fiducials. (its tough to do breath holds for 25 treatments) I have only treated several pts this way. Obviously, you need to do ct sim with contrast; would like to know if others are giving the contrast during the 4d sim or free breathing?

 

[Radiator20]

There is at least some doubt about whether post-FOLFIRINOX CT accurately identifies those who remain unresectable:
Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer. - PubMed - NCBI
Predictors of Resectability and Survival in Patients with Borderline and Locally Advanced Pancreatic Cancer who Underwent Neoadjuvant Treatment wit... - PubMed - NCBI

But if he is also medically unfit for surgery, then technical resectability is a moot point.

 

[seper]

I usually do 50 Gy/25 in post-chemo patients who can walk. If mostly bedbound, 30 Gy/10.

 

[Radiator20]

No difference in OS per LAP-07

True, but it did show a LC benefit with minimal toxicity, and avoiding/delaying this guy getting a malignant biliary obstruction seems like a big QOL win.

if others are giving the contrast during the 4d sim or free breathing

Free breathing

 

[evilbooyaa]

Like you, I also put a good margin on the prv. I use fiducials and a compression belt on these pts and am at machine for first several treatments. Try to define bowel, tumor on 50% phase, and line up to 50% fiducials. (its tough to do breath holds for 25 treatments) I have only treated several pts this way. Obviously, you need to do ct sim with contrast; would like to know if others are giving the contrast during the 4d sim or free breathing?

Why do you say that (the bolded)? We do DIBH for 3-field breasts for 25 fractions all the time. Granted (at least in the cases I've seen) pancreas movement is minimal on 4DCT. But again, my institution isn't willing to adopt these fractionation schemes, so maybe I'm out of my element here.

True, but it did show a LC benefit with minimal toxicity, and avoiding/delaying this guy getting a malignant biliary obstruction seems like a big QOL win.

Don't disagree with presence of LC and its benefits. It was brought up as 'questionable OS benefit' initially and just wanted to clarify that. Just saying I wouldn't tell the patient that I think this is going to make him live longer. Could radiate at symptomology (if he develops symptoms prior to expiring) as a reasonable option as well with a more standard palliative dose.

 

[nkmiami]

Why do you say that (the bolded)? We do DIBH for 3-field breasts for 25 fractions all the time. Granted (at least in the cases I've seen) pancreas movement is minimal on 4DCT. But again, my institution isn't willing to adopt these fractionation schemes, so maybe I'm out of my element here.



Don't disagree with presence of LC and its benefits. It was brought up as 'questionable OS benefit' initially and just wanted to clarify that. Just saying I wouldn't tell the patient that I think this is going to make him live longer. Could radiate at symptomology (if he develops symptoms prior to expiring) as a reasonable option as well with a more standard palliative dose.

with pancreas, it is imrt, and I use breath hold at exhilation as that is reproducible, so it makes the treatment harder on the patient.

 

[Gfunk6]

Breath hold for breast cancer (using tangents) vs breath hold with more complex treatments is not the same. Even with speedy treatments like VMAT, it is a burden for low KPS patients to breath hold.

 

[evilbooyaa]

with pancreas, it is imrt, and I usually have done breath hold at exhilation as that is reproducible, so it makes the treatment harder on the patient.

Breath hold for breast cancer (using tangents) vs breath hold with more complex treatments is not the same. Even with speedy treatments like VMAT, it is a burden for low KPS patients to breath hold.

Fair enough. How much movement is there in the pancreas during normal breathing?

 

[nkmiami]

Fair enough. How much movement is there in the pancreas during normal breathing?

I find that pancreas often is more mobile than most lung tumors. It is often quite significant (1cm or more). I have good dampening with a low cost compression belt (like a big blood pressure cuff from q-fix) Over the past year or so- depending on the circumstances- I have gotten away from an itv in some cases and am matching and contouring on the 50% phase which I find aligns to a free breathing cone beam.

 

[OTN]

I find that pancreas often is more mobile than most lung tumors. It is often quite significant (1cm or more). I have good dampening with a low cost compression belt (like a big blood pressure cuff from q-fix) Over the past year or so- depending on the circumstances- I have gotten away from an itv in some cases and am matching and contouring on the 50% phase which I find aligns to a free breathing cone beam.

I use the Body Pro Lok system with plate-based abdominal compression to patient tolerance, and I've seen much less pancreatic motion than lung motion. Data supports increasing abdominal compression, especially in the pancreas, to limit motion: Four-dimensional computed tomography scan analysis of tumor and organ motion at varying levels of abdominal compression during stereotactic treatme... - PubMed - NCBI