Role and place of radiotherapy in neoadjuvant treatment of pancreatic cancer

Background. The benefit of radiotherapy in the treatment of pancreatic cancer has remained a matter of discussion for decades [1]. Many controversies exist in regard to radiotherapy and its combination with other therapeutic modalities for pancreatic cancer.Purpose - to find out surgical advantages of the combined neoadjuvant therapy (NAT) for pancreatic cancer with an emphasis on induction of local fibrosis of a pancreas and its influence on postoperative morbidity. To address the special role of radiation therapy in combined NAT. To recall the current randomized control trials (RCTs) on this topic. To discuss the current state of stereotactic body radiotherapy (SBRT) in NAT.Materials and methods. MEDLINE/PubMed, Scopus and Web of Science bases were used for the purpose of literature search. The search was performed among English literature sources by the following key words: pancreatic cancer; neoadjuvant radio-therapy (NART); postoperative pancreatic fistula (POPF); pancreatic fibrosis; stereotactic body radiotherapy (SBRT). Meta-analyses, systematic examinations and RCTs, as well as retrospective research were considered. 44 publications out of 148 which satisfied the search criteria were selected. The data of the latest search: 20.02.2022. Results and discussion. Among the advantages of NAT are better compliance for neoadjuvant chemotherapy (NACT) or neoadjuvant chemoradiotherapy (NACRT), the opportunity for selection of patients with non-metastatic disease, who may further benefit from surgical resection demonstrating long term survival; treatment of putative micro-metastatic disease which cannot be detected at treatment initiation, and higher probability of achieving better tumor and nodal downstaging, and increase in R0-resection rate. The issue of neoadjuvant radiotherapy (NART) in the context of combined NAT of pancreatic cancer is discussed. Oncological and surgical benefits are presented. The role of SBRT and current state of the problem is elucidated. Ongoing RCTs are mentioned. Neoadjuvant SBRT after multiagent induction chemotherapy may be the future trend in NART of pancreatic cancer.Conclusions. SBRT is advocated as a beneficial technique which can be conducted in specialized centers after induction NACT in patients with non-metastatic pancreatic cancer with vascular invasion, no clear signs of radiological response and good performance status.