gms | German Medical Science

Neoadjuvant therapy has not been established yet in pancreatic carcinoma. Despite curative resection, local recurrence develops in 50-80% of the patients. Dependent on the quality of histological work-up, there is a variably high rate of R1 resections, above all at the retroperitoneal margin of resection by perineural infiltration. As a matter of fact, neoadjuvant, locoregional therapy seems valuable, particularly in pancreatic carcinoma.

Two large phase III studies on adjuvant chemotherapy could demonstrate an improvement in median survival (ESPAC-I: 19.7 vs. 14 months) [Neoptolemos et al., Lancet 2001] and progression-free survival (CONKO-I: 14.2 vs. 7.5 months) [Neuhaus et al., ASCO 2005]. In the ESPAC-I study a fundamental problem of adjuvant therapy became obvious: only 50 % of the patients received the scheduled treatment, 33 % less than the six cycles of chemotherapy as planned and 17 % no chemotherapy at all. The results in these studies are not yet superior to those report in centres after surgery alone.

Evidence for the effectiveness of combined chemoradiation was published by Snady et al. [Cancer 2000]. Locally advanced, non-resectable pancreatic carcinoma were primarily treated by chemoradiation, a further group with resectable tumors primarily underwent surgery. Those tumors which were rendered resectable following chemoradiation (n=20/68), i.e. the worse group in terms of prognosis, had a significantly better median survival (23 months) than primarily resected patients (91/91, n=14 months).

Presently, the value of neoadjuvant chemoradiation versus surgery alone in resectable ductal carcinoma of the pancreatic head without distant metastases is investigated in a prospective-randomised multicenter study, initiated by the CAO/ARO/AIO (50,4 Gy + 5,4 Gy boost locally, SD 1,8 Gy, 30 mg/m2 cisplatin, 300 mg/m2 gemcitabine day 1,8,22,29). Resectability is evaluated by multislice helical computed tomography and assumed if circumferential tumor contact to peripancreatic major vessels is less than 180 °. Malignancy must be confirmed before inclusion into the study by histologic or cytologic biopsies (contact: studienzentrum@chir.imed.uni-erlangen.de).