To prospectively evaluate the role of radiotherapy

on pancreatic cancer treatment, several randomized trials have been conducted with conflicting results. Hence, the routine utilization of radiation for pancreatic cancer remains controversial. This review will discuss the role of rationale for using radiation therapy (RT) in the management of pancreatic cancer, review the relevant literature, and discuss current ongoing research and future directions. Neoadjuvant radiotherapy A neoadjuvant treatment strategy in pancreatic cancer Inhibitors,research,lifescience,medical may offer several theoretical advantages: 1. Pancreatic cancer is more likely a systemic disease with high incidence of distal and local regional failure (10),(11). By starting systemic treatment early we may be able to reduce the incidence Inhibitors,research,lifescience,medical of distal metastasis and improve survival. 2. Neoadjuvant radiotherapy with or without systemic therapy may potentially downstage the

disease and increase likelihood of a complete resection (R0 resection). 3. Radiotherapy can be better tolerated because the normal anatomy of the abdominal region by surgery, such as bowel displacement, which could lead to higher gastrointestinal toxicity, has not been distorted. 4. Neoadjuvant radiotherapy can avoid treating hypoxic tumor tissue caused by surgical disruption of blood supply to tumor cells. In addition, Inhibitors,research,lifescience,medical cytokine stimulation after surgery can also potentially adversely affects the efficacy of adjuvant treatment, which can be avoided by neoadjuvant RT (25). 5. Neoadjuvant treatment may also identify those patients with aggressive disease who are likely to develop early metastatic disease, and

Inhibitors,research,lifescience,medical Z-VAD-FMK chemical structure therefore avoid unnecessary definitive surgical therapy. Given these various rationales for neoadjuvant treatment, several institutions have used this strategy in an effort to improve the survival outcome of patients with pancreatic cancer (Table 1). However, there have been no large randomized controlled trials on the use of neoadjuvant therapy in resectable pancreatic cancer. Table 1 Selected studies of neoadjuvant CRT in pancreatic Inhibitors,research,lifescience,medical cancer The Duke University study investigated neoadjuvant CRT in 96 resectable patients. Patients received daily-fractionated radiotherapy to a total dose of 50.4 Gy concurrent with 5-FU-based chemotherapy. Patients were then re-staged after completion of CRT. Patients were then surgically explored if there was no evidence of metastatic disease. Subsequently, 70% of patients underwent heptaminol surgery and 55% had a resection. A R0 resection was achieved in 75% of patients and operative mortality was 3.8%. Overall survival (OS) for resected patients was 28% at 5 years, and a median survival was 23months (26),(27). MD Anderson Cancer Center reported their neoadjuvant treatment results using two different treatment strategies. In their first trial, patients received neoadjuvant gemcitabine and radiotherapy followed by surgery.