Integrating radiation oncology into the management of pancreatic cancer

Summary Although some improvements have been made in recent years, the prognosis of pancreatic ductal adenocarcinoma remains poor. Surgical resection followed by adjuvant systemic therapy is the only curative treatment option in early stage disease. The role of radiotherapy in the treatment of pancreatic cancer is not well defined and still controversially discussed. Following the results of the ESPAC-1 trial, adjuvant radiochemotherapy (RCT) was no longer employed in most European countries. Nevertheless, in high-risk situations for local recurrence, the addition of adjuvant radiochemotherapy to adjuvant systemic therapy should be discussed, as it may lead to prolonged local tumor control. In resectable tumors, neoadjuvant radiochemotherapy or stereotactic body radiation therapy combined with systemic therapy showed encouraging results in phase I/II trials without increasing postoperative morbidity. Until the results of prospective randomized trials are available, neoadjuvant therapy in resectable pancreatic cancer is only recommended in clinical trials. In borderline resectable and locally advanced tumors, the addition of radiochemotherapy to systemic therapy leads to improved tumor response, and 20–30% of locally advanced tumors can be resected after neoadjuvant therapy. In locally advanced tumors with stable disease after systemic therapy, the addition of radiochemotherapy should be discussed to increase local control and prolong time to local progression. Modern radiotherapy with image guidance, intensity-modulated radiotherapy, and stereotactic body radiotherapy offer new perspectives for the future and will be part of modern multimodal treatment concepts to improve the outcome of pancreatic cancer.