Be Best.

Top Line: It's a motto to live by, and when treating borderline resectable pancreatic cancer it may mean using a total neoadjuvant therapy (TNT) approach.
The Study: Everyone is talking about TNT for GI cancers, except Melania who forgot to mention it in her platform yesterday. This phase 2 trial evaluated the efficacy of TNT for 48 patients with borderline resectable pancreatic cancer. TNT consisted of FOLFIRINOX x 4 followed by restaging. If you didn’t progress, you got 4 more cycles followed again by restaging. Then, those with no vascular involvement went for short course radiation (25 Gy in 5 fractions using protons or 30 Gy in 10 fractions using photons) and surgery, while those with persistent vascular involvement went for long course radiation alone (50.4 Gy in 28 fractions with a simultaneous boost to a total of 58.8 Gy to the vascular margin), and concurrent capecitabine was given with both. Two important takeaways were that [1] over 80% of patients completed TNT and [2] 31/32 (97%) patients who underwent surgery achieved an R0 resection. This means that 65% of the entire cohort had a potentially curative resection. Whoa. This trial represents the shifting treatment paradigm happening in pancreatic cancer, highlighted by the ongoing Alliance A021501 trial randomizing borderline resectable patients to neoadjuvant FOLFIRINOX x 8 versus FOLFIRINOX x 7 + SBRT. Importantly, conventionally fractionated radiation (aka long course, may it rest in peace) has been dropped from that trial altogether.
Bottom Line: Two-thirds of patients with borderline resectable pancreatic cancer receiving TNT go on to have an R0 resection, which sounds like a good way to be best. | Murphy, JAMA Oncol 2018


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