Management of resectable and borderline resectable disease: Radiation oncology

Surgical resection is the mainstay of curative treatment for pancreatic cancer. However, relapse rates with surgery alone are high. As systemic therapy improves, patients are living longer without metastatic disease. These improvements in distant control have increased the importance of optimizing local control. Historically, radiotherapy has been given in the postoperative setting to decrease local relapse after surgery. The indications and sequencing of radiotherapy are shifting, with increasing interest in a preoperative approach. Advances in radiotherapy have also made it possible to deliver higher doses to specific volumes. This may help expand the role of radiotherapy in the treatment of locally advanced and/or inoperative pancreatic cancer. Advances in target delineation, motion management, and image guidance have greatly improved the therapeutic ratio. More conformal radiation modalities such as intensity-modulated radiation therapy, stereotactic body radiation therapy, and particle therapy may offer further dose optimization to the tumor while sparing nearby organs from toxicity.