Multimodality therapy of localized unresectable pancreatic adenocarcinoma

Eighty-eight patients with localized unresectable carcinoma of the pancreas were treated at Thomas Jefferson University Hospital between 1974 and 1981. Four treatment regimens were used which were sequential modifications of the technique based on the experience in the preceding group of patients. Each treatment changed the course of the disease, and as patterns of failure were identified, the treatment was altered to deal with them. Initially, all patients were treated with external beam radiation. Subsequently, Iodine-125 implantation was added to improve local control; low-dose preoperative radiotherapy to reduce the risk of peritoneal seeding; and adjuvant chemotherapy to reduce the risks of distant metastases. The addition of 125I implantation increased the local control from 22% to 81%, but did not increase the median survival, which was unchanged from 7 months. The addition of adjuvant chemotherapy increased the median survival from 7 months to 14 months, but had no impact on the control of the pancreatic tumor. Adjunctive chemotherapy and low-dose preoperative radiotherapy appear synergistic in reducing the risk of peritoneal seeding. The combination of 125I implantation, external beam radiation, and adjunctive chemotherapy is safe and effective. This regimen produces excellent local control with acceptable morbidity. This regimen produced a 30% survival at 18 months. The patterns of failure among these patients suggest future modifications of the technique.