Stereotactic body radiotherapy in the treatment of pancreatic adenocarcinoma in elderly patients

Carolyn H Kim, Diane C Ling, Rodney E Wegner, John C Flickinger, Dwight E Heron, Herbert Zeh, Arthur J Moser, Steven A Burton, Carolyn H Kim, Diane C Ling, Rodney E Wegner, John C Flickinger, Dwight E Heron, Herbert Zeh, Arthur J Moser, Steven A Burton

Abstract

Background: Treatment of pancreatic adenocarcinoma in the elderly is often complicated by comorbidities that preclude surgery, chemotherapy and/or conventional external beam radiation therapy (EBRT). Stereotactic body radiotherapy (SBRT) has thus garnered interest in this setting.

Methods: A retrospective review of 26 patients of age ≥ 80 with pancreatic adenocarcinoma treated with definitive SBRT+/-chemotherapy from 2007-2011 was performed. Twenty-seven percent of patients were stage I, 38% were stage II, 27% were stage III and 8% were stage IV. Patients most commonly received 24 Gy/1 fraction or 30-36 Gy/3 fractions. Kaplan-Meier was used to estimate overall survival (OS), local control (LC), cause specific survival (CSS) and freedom-from-metastatic disease (FFMD).

Results: The median age was 86 (range 80-91), and median follow-up was 11.6 months (3.5-24.6). The median planning target volume was 21.48 cm3 (6.1-85.09). Median OS was 7.6 months with 6/12 month OS rates of 65.4%/34.6%, respectively. Median LC was 11.5 months, 6-month and 12-month actuarial LC rates were 60.1% and 41.2%, respectively. There were no independent predictors for LC, but there was a trend for improved LC with prescription dose greater than 20 Gy (p = 0.063). Median CSS was 6.3 months, and 6-month and 12-month actuarial CSS were 53.8% and 23.1%, respectively. Median FFMD was 8.4 months, and 6-month and 12-month actuarial rates were 62.0% and 41.4%, respectively. Nine patients (47%) had local failures, 11 (58%) had distant metastasis, and 7 (37%) had both. There were no acute or late grade 3+ toxicities.

Conclusions: Definitive SBRT is feasible, safe and effective in elderly patients who have unresectable disease, have comorbidities precluding surgery or decline surgery.

Figures

Figure 1
Figure 1
Axial view of a stereotactic radiosurgery plan via TrueBeam™-IMRS (Varian Medical Systems, Palo Alto, CA) delivering 36 Gy given in 3 fractions to an 88 year old female. PTV is shown in red. Blue colorwash outline shows 80% prescribed isodose line. Critical structures are outlined as follows: kidneys (yellow), liver (orange), bowels (brown), and spinal cord (blue).
Figure 2
Figure 2
Overall survival for all patients from time of SBRT. The median OS was 7.6 months. Six-month and 12-month OS rates were 65.4% and 34.6%, respectively.
Figure 3
Figure 3
Local control for all patients from time of SBRT. Median LC was 11.5 months. Six-month and 12-month actuarial LC rates were 60.1% and 41.2%, respectively.
Figure 4
Figure 4
Time to distant failure for all patients. The overall median time of freedom from distant metastases was 8.4 months with a 6-month and 12-month actuarial rates of 62.0% and 41.4%, respectively.
Figure 5
Figure 5
Cause specific survival. The overall median CSS was 6.3 months with a 6-month and 12-month actuarial rates of 53.8% and 23.1%, respectively.

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