Results and follow-up of locally advanced cancer of the exocrine pancreas treated with radiochemotherapy.

UNLABELLED: In locally advanced carcinoma of the exocrine pancreas combined radiochemotherapy has been established as a standard treatment. MATERIALS AND METHODS: Two different treatment schemes have been consecutively used. Between 1/1994 and 12/2001, a total of 110 patients with locally advanced adenocarcinoma of the pancreas were treated with hyperfractionated accelerated radiotherapy to a total dose of 44.8 Gy combined with 5-fluorouracil (5-FU) (600 mg/m2) and folinic acid (FA) (300 mg/m2) injection. Chemotherapy was repeated monthly in non-progressive disease. From 1/2002 to 11/2003, in another 15 consecutive patients, chemotherapy was changed to gemcitabine (Gem) (300 mg/m2) and cisplatinum (Cis) (30 mg/m2), followed by gemcitabine (1000 mg/m2) every 2 weeks in non-progressive patients. RESULTS: Median survival in the 5-FU/FA group was 10.3 months with a 1-year survival of 46.6% and a 2-year survival of 20.1%. Median time to progression was 8.6 months. Treatment was well tolerated with nausea/vomiting grade I/II in 58.2%, grade III/IV in 14.5%, diarrhea grade I/II in 27.3%, leucopenia/thrombopenia grade I/II in 21.8%, grade III/IV in 7.2%, and mucositis grade III/IV in 7.2%. In the Gem/Cis group, median survival was 13.8 months with a 1-year survival of 54.9% and a 2-year survival of 24.4%. The toxicity data also revealed comparable feasibility: nausea/vomiting grade I/II in 46.7%, grade III/IV in 20%, diarrhea grade I/II in 20%, leucopenia/thrombopenia grade I/II in 26. 7%, and grade III/IV in 13.3%. CONCLUSION: Radiochemotherapy in locally advanced pancreatic cancer is an effective and well-tolerated treatment. The long-term efficacy concerning survival is limited. The integration of predictive factors and new chemotherapeutic agents like gemcitabine in the multimodality treatment may give a more promising perspective. Because of the narrow therapeutic index of gemcitabine-based radiochemotherapy schemes, a feasible combination of radiotherapy treatment volume and gemcitabine dose must be found.

Predictive value of carbohydrate antigen 19-9 in pancreatic cancer treated with radiochemotherapy.

PURPOSE: To determine the predictive value of carbohydrate antigen (CA) 19-9 in pancreatic cancer treated with radiochemotherapy. METHODS AND MATERIALS: Ninety-five patients with locally advanced unresectable adenocarcinoma of the pancreas were treated with hyperfractionated accelerated radiotherapy to a total dose of 44.8 Gy combined with 5-fluorouracil and folinic acid. CA 19-9 was measured before therapy, each week during therapy, and every 4 weeks during the follow-up period. RESULTS: The median CA 19-9 before treatment was 420 U/mL; in the responder group it was 117 U/mL, and in the nonresponder group it was 806 U/mL. Patients with a pretreatment CA 19-9 less than the median had not only a significantly better tumor response (45.8%) but also a better survival prognosis (median survival 12.3 months) than those with a level higher than the median (tumor response 12.8%; median survival 7.1 months). The posttreatment median CA 19-9 for all patients also exhibited prognostic significance. The median survival of patients with a CA 19-9 level lower than the posttreatment median of 293 U/mL was 13.5 months, compared with 7.2 months for those with a CA 19-9 level greater than the median. To detect recurrent disease during follow-up, the sensitivity of CA 19-9 was 100% and the specificity 88%. CONCLUSION: Our results indicate that CA 19-9 is of predictive value for prognosis, response, and detecting recurrence of pancreatic cancer in patients undergoing combined radiochemotherapy. Therefore, we recommend the routine implementation of CA 19-9 observation during the clinical course of treatment for patients with pancreatic cancer undergoing radiochemotherapy.

CA 19-9 in the therapy monitoring and follow-up of locally advanced cancer of the exocrine pancreas treated with radiochemotherapy.

PURPOSE: The aim of this study was to determine the value of CA 19-9 in therapy monitoring and follow-up of locally advanced pancreatic cancer treated by radiochemotherapy. MATERIALS AND METHODS: Ninety-five patients with locally advanced irresectable adenocarcinoma of the pancreas were treated with hyperfractionated accelerated radiotherapy, with 44.8 Gy and 5-fluorouracil and folinic acid, January 1994 between and June 2001. CA 19-9 was measured before therapy, each week under therapy and every 4 weeks in the follow-up. RESULTS: Median CA 19-9 before treatment was 420 U/ml. Patients with a level below the median had significantly better prognosis and a better treatment response than those above the median. In the follow-up CA 19-9 had a sensitivity of 100% in detection of recurrent disease with a specificity of 88. CONCLUSION: CA 19-9 has a high prognostic value and may serve as an in vivo marker for treatment sensitivity. For detection of recurrent disease it shows a high sensitivity and specificity.

The clinical value of squamous cell carcinoma antigen in patients irradiated for locally advanced cancer of the head and neck.

PURPOSE: This study examines the value of squamous cell cancer (SCC) antigen in patients irradiated for locally advanced cancer of the head and neck. MATERIALS AND METHODS: In 20 patients (group A) treated with radiochemotherapy and in 20 patients (group B) receiving postoperative irradiation serum SCC values were investigated. RESULTS: The pretreatment SCC level was 1.6 ng/ml in group A and 1.3 ng/ml in group B. In group A 15% had elevated serum SCC levels above the cut-off level. In group B there were 10%. During follow-up (median 20 months), 10 patients in group A and 8 in group B suffered from a recurrent or progressing disease. Of these 20% in group A and 12.5% in group B had elevated SCC levels. CONCLUSION: Our results suggest that, in the described patient groups, SCC is probably of low value for tumor diagnosis and follow-up.

Accelerated radiochemotherapy in pancreatic cancer is not necessarily related to a pathologic pancreatic function decline in the early period.

PURPOSE: To evaluate the functional effects of ionizing radiation in patients with unresectable pancreatic cancer in the early period after accelerated radiochemotherapy (ART). METHODS AND MATERIALS: To analyze the exocrine component, the amino acid consumption test and fecal elastase 1 were performed in 13 patients immediately before and 4-8 weeks after ART. Pancreatic duct morphology was evaluated before therapy. Weight loss and clinical steatorrhea were recorded. Endocrine parameters were examined according to standardized criteria. RESULTS: The relative change of the amino acid consumption test results and the median elastase concentration was 41.2% and 56.4%, respectively. Five patients still had normal test results after ART and 5 patients developed pathologic values. The median relative weight loss of the total body weight was 7.7% +/- 4.5%. No steatorrhea occurred. Of the 5 patients with normal values, 3 had a mean organ dose of <40 Gy. Of the 5 patients with pathologic values, 4 had a mean organ dose of >41 Gy. The endocrine function measurements remained unchanged. CONCLUSION: Although a nominal reduction of exocrine function parameters occurred in most patients, ART was not necessarily related to a pathologic level in the early period. Diabetes was not established. The functional impairment that was existent in the patient population presumably contributed to the weight loss. Pancreatic enzyme preparations may also play a role in maintaining an anabolic state during and after radiochemotherapy.

Conformal therapy for pancreatic cancer: variation of organ position due to gastrointestinal distention--implications for treatment planning.

PURPOSE: To quantify nonrespiratory organ motion in the pancreatic region and its effect on clinical target volume. MATERIALS AND METHODS: Three-dimensional translations of the geometric centers of the volumes of interest--pancreatic head, body, and tail; left and right kidney; and the superior mesenteric artery--were measured in 20 patients by analyzing three spiral computed tomographic (CT) protocols performed at static exhalation and representing differential gastrointestinal distention. Wilcoxon test for paired differences was applied to determine statistical significance (P <.05). Spearman rank correlation coefficients were calculated between combinations of statistically significant translations. With the assumption that the organ positions were represented by a three-dimensional Gaussian distribution that occurs during treatment, clinical target volume expansions were calculated to account for organ motion and a typical setup error. RESULTS: Significant translations of the volume of interest were observed. The most mobile parts of the target organs were the pancreatic tail (P =.001) and the superior mesenteric artery (P =.01). Larger variations from the mean in the planning CT protocol in which negative contrast material was used usually resulted in a slightly larger clinical target volume expansion. CONCLUSION: Our data may provide a basis for further studies of organ motion and ways of modifying treatment margins.