Technical aspects of modern radiation therapy for pancreatic adenocarcinoma: field design, motion management, dosing, and concurrent therapy

The role of radiation for pancreatic cancer has historically been controversial with multiple randomized trials reporting conflicting results in both the adjuvant and locally advanced setting. However, most of the phase III trials for pancreatic cancer employed antiquated radiation techniques, rendering their applicability to the question of the role of modern day radiation unclear. Indeed, recent advances in treatment planning, motion management, and image guidance have provided radiation oncologists with a new armamentarium to solve the challenge of delivering sufficiently high dose to a highly mobile target that is surrounded by exquisitely radiosensitive structures, with recent data providing significant reason for optimism about the role of radiation across all stages of pancreatic cancer. Herein, we review the technical aspects of the delivery of modern radiation delivery for pancreatic cancer, both as neoadjuvant and definitive therapy for intact pancreatic tumors as well as adjuvant therapy for resected pancreatic tumors. We discuss each step of the radiation process, from simulation to contouring to treatment planning to treatment delivery, with a focus on recent data addressing critical questions as well as the strategies that have been employed to address these questions. A detailed understanding of these technical considerations is critical for any radiation oncologist treating pancreatic cancer, but also for medical and surgical oncology colleagues integrating multi-disciplinary care. Fluency in this information will yield an appreciation of the potential for radiation for patients with pancreatic cancer as well as the remaining challenges ahead.