Neoadjuvant Chemoradiotherapy Using Moderately Hypofractionated Intensity-Modulated Radiotherapy Versus Upfront Surgery for Resectable Pancreatic Cancer: A Retrospective Cohort Study

• Published in: Annals of surgical oncology Vol. 32; no. 5; pp. 3603 - 3613
• Main Authors: Yamane, Kei, Anazawa, Takayuki, Nagai, Kazuyuki, Kasai, Yosuke, Masui, Toshihiko, Izuwa, Aya, Kurahashi, Koki, Ishida, Satoshi, Ogiso, Satoshi, Yoshimura, Michio, Iwai, Takahiro, Matsubara, Junichi, Fukuda, Akihisa, Isoda, Hiroyoshi, Hidaka, Yu, Ibi, Yumiko, Hatano, Etsuro
• Format: Journal Article
• Language: English
• Published: Cham Springer International Publishing 01.05.2025; Springer Nature B.V
• Subjects: Adenocarcinoma; Adult; Aged; Carcinoma, Pancreatic Ductal - mortality; Carcinoma, Pancreatic Ductal - pathology; Carcinoma, Pancreatic Ductal - therapy; Chemoradiotherapy; Chemoradiotherapy, Adjuvant - mortality; Chemotherapy; Complications; Female; Follow-Up Studies; Humans; Lymph nodes; Male; Medicine; Medicine & Public Health; Metastases; Middle Aged; Multivariate analysis; Neoadjuvant Therapy - mortality; Oncology; Pancreatectomy - mortality; Pancreatic cancer; Pancreatic Neoplasms - mortality; Pancreatic Neoplasms - pathology; Pancreatic Neoplasms - therapy; Pancreatic Tumors; Patients; Postoperative; Prognosis; Radiation Dose Hypofractionation; Radiation therapy; Radiotherapy, Intensity-Modulated - methods; Radiotherapy, Intensity-Modulated - mortality; Retrospective Studies; Surgery; Surgical Oncology; Survival; Survival Rate; Toxicity
• ISSN: 1068-9265; 1534-4681; 1534-4681
• DOI: 10.1245/s10434-025-16956-z

Background The efficacy of neoadjuvant chemoradiotherapy for resectable pancreatic ductal adenocarcinoma (R-PDAC) remains unclear. This study was designed to evaluate neoadjuvant chemoradiotherapy by using intensity-modulated radiotherapy (NAC-IMRT) for R-PDAC compared with upfront surgery (UpS). Methods Among 198 patients with R-PDAC who were indicated for resection between 2013 and 2021, 130 were included in this study after excluding patients who underwent neoadjuvant chemotherapy and did not meet the NAC-IMRT criteria (Eligible set). NAC-IMRT was planned for 58 patients, and UpS was planned for 72 patients. Additionally, in 105 patients who could undergo the planned treatment (As-treated set), the surgical, pathological, and oncological outcomes were evaluated. Results In the Eligible set, median overall survival (OS) was 50.5 months with NAC-IMRT and 34.7 months with UpS and progression-free survival was 20.4 months with NAC-IMRT and 13.9 months with UpS. In the As-treated set, OS was longer in the NAC-IMRT group (66.7 months vs. 34.7 months, p = 0.007). On multivariate analysis, NAC-IMRT was identified as an independent factor for better OS (hazard ratio 0.617, 95% confidence interval 0.382–0.995, p = 0.047, in the Eligible set). The incidence of postoperative complications did not show a difference between the two groups, and NAC-IMRT suppressed local tumor invasion, including lymphatic, venous, perineural invasion, and lymph node metastases. Conclusions NAC-IMRT may offer superior survival outcomes and manageable toxicity in R-PDAC patients compared with upfront surgery. This study supports the efficacy and safety of NAC-IMRT and recommends its consideration in R-PDAC treatment protocols.