Successful Retreatment with Chemoradiotherapy for Local Recurrence of Pancreatic Adenocarcinoma after Neoadjuvant Therapy and Pancreaticoduodenectomy.

CASE REPORT A 68-year-old man with a history of diabetes and alcohol abuse presented with constitutional symptoms and obstructive jaundice in April 2009. Endoscopic ultrasound (EUS) demonstrated a 3.2 2-cm mass in the head of the pancreas, abutting the portal vein and encasing the common bile duct. A biopsy was positive for adenocarcinoma, and the tumor was judged to be borderline resectable. The patient was treated with neoadjuvant docetaxel and gemcitabine for 3 cycles, followed by twice-weekly gemcitabine 50 mg/m and external beam radiotherapy (total dose, 54 Gy by intensity-modulated radiation therapy [IMRT]), per Pipas et al. Treatment induced a 25% reduction in tumor size at restaging, despite an initial delay and dose reductions related to prolonged elevation in results of liver function studies after biliary stenting. In November 2009, the patient underwent pancreaticoduodenectomy. Pathology revealed an invasive, poorly differentiated pancreatic adenocarcinoma with treatment-related change. Surgical margins and 22 lymph nodes were negative for tumor. The postoperative course was complicated by a 6-week hospital stay for ascites and poor wound healing, due to previously unrecognized alcoholic cirrhosis. The patient eventually made a full recovery and returned to work, but in June 2010, he presented for a surveillance abdominal computed tomographic (CT) scan that showed an irregularity in the pancreatic remnant (Figure 1). A repeat EUS demonstrated a 3-cm pancreatic tail mass that encased splenic vessels, and adenocarcinoma was confirmed by biopsy. Comparison with the prior tumor by light microscopy and immunohistochemistry revealed the specimens to be identical. In addition, massively parallel sequencing of a 50-gene cancer hotspot panel in DNA extracted from both tumors revealed a single PIK3CA polymorphism that was the same in each, thus confirming that the lesion represented recurrent tumor and not a second primary. The patient was not a candidate for completion pancreatectomy because of the cirrhosis. His case was presented at our interdisciplinary GI tumor board, and he was retreated with twice-weekly gemcitabine 50 mg/m, concurrent with radiotherapy in nonoverlapping fields. He received 45 Gy with 3-D conformal planning. The previous radiation plan was fused to avoid overdosing of critical structures. Conformal planning was chosen over IMRT to avoid radiation dose spillage into the previously treated tumor bed (Figure 2). The patient completed chemoradiotherapy (CRT) in September 2010 with a 50% reduction in tumor size and normalization of CA 19-9. Three of 12 planned doses of gemcitabine were cancelled for thrombocytopenia and/or diarrhea. Treatment was well tolerated, except for some weight loss and depression, which was managed with mirtazapine. Re-resection was considered, but the cirrhosis was thought to pose too great a surgical risk. The patient was subsequently followed up for recurrence with twice-yearly CT scans. The most recent scan demonstrated stable 1.5-cm hypodensity in the tail of the pancreas, with no evidence of progression or metastases (Figure 3), and CA 19-9 was 24 U/mL (normal, 34.9 U/mL). The patient remained alive and free of disease progression 48 months from the time of initial diagnosis and 34 months from the time of recurrence.