Radiation Therapy For Pancreatic Cancer
Publication Date: September 1, 2019
Last Updated: March 14, 2022
Recommendations
Indications for conventionally fractionated RT or SBRT
Following surgical resection of pancreatic cancer, adjuvant conventionally fractionated RT with chemotherapy in select high-risk patients is conditionally recommended. (Conditional (weak), Low)
Implementation Remark:
- High-risk clinical features would include positive lymph nodes and margins regardless of tumor location within the pancreas.
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Following surgical resection of pancreatic cancer, adjuvant SBRT is only recommended on a clinical trial or multi-institutional registry. (Strong, Very low)
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For patients with resectable pancreatic cancer, neoadjuvant therapy is conditionally recommended. (Conditional (weak), Low)
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For patients with borderline resectable pancreatic cancer and select locally advanced pancreatic cancer appropriate for downstaging prior to surgery, a neoadjuvant therapy regimen of systemic chemotherapy followed by conventionally fractionated RT with chemotherapy is conditionally recommended. (Conditional (weak), Moderate)
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For patients with borderline resectable pancreatic cancer and select locally advanced pancreatic cancer appropriate for downstaging prior to surgery, a neoadjuvant therapy regimen of systemic chemotherapy followed by multifraction SBRT is conditionally recommended. (Conditional (weak), Low)
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For patients with locally advanced pancreatic cancer not appropriate for downstaging to eventual surgery, a definitive therapy regimen of systemic chemotherapy followed by either (1) conventionally fractionated RT with chemotherapy, (2) dose-escalated chemoradiation, or (3) multifraction SBRT without chemotherapy is conditionally recommended. (Conditional (weak), Low)
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Dose fractionation and target volumes
For patients with resected pancreatic cancer selected for adjuvant conventionally fractionated RT and chemotherapy, 4500-5400 cGy in 180-200 cGy fractions with concurrent 5-fluorouracilebased chemotherapy is recommended. (Strong, Moderate)
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For patients with borderline resectable pancreatic cancer selected for neoadjuvant conventionally fractionated RT and chemotherapy, 4500-5040 cGy in 180- 200 cGy fractions is conditionally recommended. (Conditional (weak), Low)
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For patients with locally advanced pancreatic cancer selected for definitive conventionally fractionated or dose-escalated RT with chemotherapy, 5040- 5600 cGy in 175-220 cGy fractions with concurrent chemotherapy is conditionally recommended. (Conditional (weak), Low)
Implementation Remark:
- A number of fractionation schemes are used for locally advanced disease
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For patients with borderline resectable pancreatic cancer selected for SBRT, 3000-3300 cGy in 600-660 cGy fractions with a consideration for a simultaneous integrated boost of up to 4000 cGy to the tumor vessel interface is conditionally recommended. (Conditional (weak), Moderate)
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For patients with locally advanced pancreatic cancer selected for SBRT, 3300- 4000 cGy in 660-800 cGy fractions is recommended. (Strong, Moderate)
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For patients with resected pancreatic head cancer receiving adjuvant RT, use of the NRG Oncology consensus panel guidance1 for clinical target volume delineation is recommended. (Strong, Moderate)
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For patients with resected pancreatic body and tail tumors receiving adjuvant RT, a clinical target volume including the pancreatic resection margin and regional nodal basins indicated in the NRG Oncology consensus panel guidance1 for pancreatic head lesions but excluding the periportal/liver hilum nodal region is recommended. (Strong, Moderate)
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For patients with borderline resectable pancreatic cancer selected for SBRT, a treatment volume including the gross tumor volume with a small margin is recommended. (Strong, High)
Implementation Remark:
- SBRT does not routinely treat elective nodes.
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For patients with locally advanced pancreatic cancer selected for SBRT, a treatment volume including the gross tumor volume with a small margin is recommended. (Conditional (weak), Moderate)
Implementation Remark:
- SBRT does not routinely treat elective nodes.
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For patients with locally advanced pancreatic cancer selected for definitive conventionally fractionated RT and chemotherapy, elective nodal treatment is conditionally recommended. (Conditional (weak), Moderate)
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Sequencing of chemotherapy and RT in patients receiving RT
For patients with resected pancreatic cancer receiving adjuvant therapy, delivery of chemoradiation following 4-6 months of systemic chemotherapy is recommended. (Strong, Moderate)
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For patients with borderline resectable pancreatic cancer receiving neoadjuvant therapy, delivery of RT following 2-6 months of systemic chemotherapy is recommended. (Strong, Moderate)
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For patients with unresectable or locally advanced pancreatic cancer without systemic progressionfollowing 4-6+ months of chemotherapy, definitive RT is recommended. (Strong, Moderate)
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Simulation considerations
For patients with pancreatic cancer receiving conventionally fractionated pancreatic RT or SBRT without breath-hold, a patient-specific respiratory motion assessment (eg, 4-dimensional [4-D] CT simulation) is recommended. (Strong, High)
Implementation Remark:
- For palliative or postoperative RT, motion assessment and management may not be required.
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For patients with pancreatic cancer receiving SBRT, a respiratory motion management technique is recommended. (Strong, High)
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For patients with pancreatic cancer receiving conventionally fractionated RT for whom free-breathing target motion is significant (>1 cm), a respiratory motion reduction technique is conditionally recommended. (Conditional (weak), Moderate)
Implementation Remarks:
- For palliative or postoperative RT, motion assessment and management may not be required.
- For respiratory motion management techniques, the end-exhalation position may be more reproducible than inhalation positions
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For patients receiving conventionally fractionated RT for pancreatic cancer, daily image guidance is recommended. (Strong, Moderate)
Implementation Remarks:
- Bony anatomy and surgical stents are each poor surrogates for pancreas target positioning; if used for image guidance, large internal target volume margins are necessary.
- Where possible, the cine (fluoroscopic) imaging is useful, in addition to 2-D or 3-D image guidance, to confirm that the ITV adequately accounts for respiratory motion variations or intraebreath-hold drift.
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For patients receiving SBRT for pancreatic cancer, daily image guidance with fiducial markers and volumetric imaging is recommended. (Strong, Moderate)
Implementation Remarks:
- Bony anatomy and surgical stents are each poor surrogates for pancreas target positioning; if used for image guidance, large internal target volume margins are necessary.
- Where possible, the use of cine (fluoroscopic) imaging is suggested, in addition to 2-D or 3-D image guidance, to confirm that the ITV adequately accounts for respiratory motion variations or intraebreath-hold drift.
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Unless there is a contraindication to IV contrast, patients with pancreatic cancer treated with RT should receive IV contrast at CT simulation; multiphasic CT with a high contrast flow rate and injection volume and patient-specific scan timing is recommended. (Strong, High)
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Treatment planning
For treatment of localized pancreatic cancer, modulated treatment techniques such as IMRT and VMAT for planning and delivery of both conventionally fractionated and hypofractionated RT are recommended. (Strong, Moderate)
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Palliative RT
For selected patients with metastatic pancreatic cancer, palliative RT to either the primary or select metastatic sites for symptom management is recommended. (Strong, Moderate)
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Recommendation Grading
Overview
Title
Radiation Therapy For Pancreatic Cancer
Authoring Organization
American Society for Radiation Oncology
Publication Month/Year
September 1, 2019
Last Updated Month/Year
December 5, 2022
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline systematically reviews the evidence for treatment of pancreatic cancer with radiation in the adjuvant, neoadjuvant, definitive, and palliative settings and provides recommendations on indications and technical considerations.
Target Patient Population
Patients with pancreatic cancer
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospice, Hospital, Long term care, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D010190 - Pancreatic Neoplasms, D018787 - Radiation Oncology, D011827 - Radiation
Keywords
pancreatic cancer, chemoradiation, radiation therapy, Adjuvant Radiation Therapy