Review Article| Volume 22, ISSUE 1, P12-23, March 2023

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The Current Role of Radiation in Pancreatic Cancer and Future Directions

  • Colin S. Hill
    Address for correspondence: Colin S. Hill, Department of Radiation Oncology, Perlmutter Cancer Center, New York University Grossman School of Medicine, 160 E. 34th St, New York, NY 10016.
    Department of Radiation Oncology, Perlmutter Cancer Center, New York University Grossman School of Medicine, New York, NY
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  • Joseph M. Herman
    Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY
    Search for articles by this author
Published:January 30, 2023DOI:


      Survival outcomes for localized pancreatic adenocarcinoma remains poor. Multimodality therapeutic regimens are critical to maximizing survival outcomes for these patients, which includes the use of systemic therapy, surgery, and radiation. In this review, the evolution of radiation techniques are discussed with a focus on modern techniques such as intensity modulated radiation and stereotactic body radiation therapy. However, the current role of radiation within the most common clinical scenarios for pancreatic cancer in the neoadjuvant, definitive, and adjuvant settings continues to be highly debated. The role of radiation in these settings is reviewed in the context of historical and modern clinical studies. In addition, emerging concepts including dose-escalated radiation, magnetic resonance-guided radiation therapy, and particle therapy are discussed to promote an understanding of how such concepts may change the role of radiation in the future.


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        • Rahib L
        • Wehner MR
        • Matrisian LM
        • Nead KT.
        Estimated Projection of US Cancer Incidence and Death to 2040.
        JAMA Netw Open. 2021; 4e214708
        • Miller TR
        • Fuller LM.
        Radiation therapy of carcinoma of the pancreas: report on 91 cases.
        Am J Roentgenol Radium Ther Nucl Med. 1958; 80: 787-792
        • Webb S
        • Evans PM.
        Innovative techniques in radiation therapy: editorial, overview, and crystal ball gaze to the future.
        Semin Radiat Oncol. 2006; 16: 193-198
      1. Ng SP, Koay EJ. Current and emerging radiotherapy strategies for pancreatic adenocarcinoma: stereotactic, intensity modulated and particle radiotherapy. Ann Pancreat Cancer. 2018 Aug;1:22. doi:10.21037/apc.2018.07.03. Epub 2018 Aug 13. PMID: 30198024; PMCID: PMC6124686.

        • Reyngold M
        • O'Reilly EM
        • Varghese AM
        • et al.
        Association of ablative radiation therapy with survival among patients with inoperable pancreatic cancer.
        JAMA Oncol. 2021;
        • Park JJ
        • Hajj C
        • Reyngold M
        • et al.
        Stereotactic body radiation vs. intensity-modulated radiation for unresectable pancreatic cancer.
        Acta Oncol. 2017; 56: 1746-1753
        • Zhong J
        • Patel K
        • Switchenko J
        • et al.
        Outcomes for patients with locally advanced pancreatic adenocarcinoma treated with stereotactic body radiation therapy versus conventionally fractionated radiation.
        Cancer. 2017; 123: 3486-3493
        • Franke AJ
        • Rosati LM
        • Pawlik TM
        • Kumar R
        • Herman JM.
        The role of radiation therapy in pancreatic ductal adenocarcinoma in the neoadjuvant and adjuvant settings.
        Semin Oncol. 2015; 42: 144-162
        • Ng SP
        • Herman JM.
        Stereotactic radiotherapy and particle therapy for pancreatic cancer.
        Cancers. 2018; 10: 75
        • Rutenberg MS
        • Nichols RC.
        Proton beam radiotherapy for pancreas cancer.
        J Gastrointest Oncol. 2020; 11: 166-175
        • Siegel RL
        • Miller KD
        • Fuchs HE
        • Jemal A.
        Cancer statistics, 2021.
        CA Cancer J Clin. 2021; 71 (Erratum in: CA Cancer J Clin. 2021;71(4):359): 7-33
        • Patel S.H.
        • Katz M.H.G.
        • Ahmad S.A.
        The landmark series: neoadjuvant therapy for pancreatic cancer.
        Ann Surg Oncol. 2021; 28: 4104-4129
        • Oettle H
        • Neuhaus P
        • Hochhaus A
        • et al.
        Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial.
        JAMA. 2013; 310: 1473-1481
      2. Moertel CG, Frytak S, Hahn RG, O’Connell MJ, Reitemeier RJ, Rubin J, Schutt AJ, Weiland LH, Childs DS, Holbrook MA, Lavin PT, Livstone E, Spiro H, Knowlton A, Kaiser M, Barkin J, Lessner H, Mann-Kaplan R, Ramming K, Douglas HO Jr, Thomas P, Nave H, Bateman J, Lokich J, Brooks J, Chaffey J, Corson JM, Zamcheck N, Novak JW. Therapy of locally unresectable pancreatic carcinoma: a randomized comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-fluorouracil), and high dose radiation + 5-fluorouracil: The Gastrointestinal Tumor Study Group. Cancer. 1981 Oct 15;48(8):1705–10. doi:10.1002/1097-0142(19811015)48:8<1705::aid-cncr2820480803>;2-4. PMID: 7284971.

        • Kaiser MH
        • Ellenberg SS.
        Pancreatic cancer:adjuvant combined radiation and chemotherapy following curative resection.
        Arch Surg. 1985; 120: 899-903
        • Klaassen DJ
        • MacIntyre JM
        • Catton GE
        • Engstrom PF
        • Moertel CG.
        Treatment of locally unresectable cancer of the stomach and pancreas: a randomized comparison of 5-fluorouracil alone with radiation plus concurrent and maintenance 5-fluorouracil–an Eastern Cooperative Oncology Group study.
        J Clin Oncol. 1985; 3: 373-378
      3. Treatment of locally unresectable carcinoma of the pancreas: comparison of combined-modality therapy (chemotherapy plus radiotherapy) to chemotherapy alone. Gastrointestinal Tumor Study Group.
        J Natl Cancer Inst. 1988; 80: 751-755
        • Klinkenbijl JH
        • Jeekel J
        • Sahmoud T
        • et al.
        Adjuvant radiotherapy and 5-fluorouracil after curative resection of cancer of the pancreas and periampullary region: phase III trial of the EORTC gastrointestinal tract cancer cooperative group.
        Ann Surg. 1999; 230: 776-784
        • Neoptolemos JP
        • Stocken DD
        • Friess H
        • et al.
        European Study Group for pancreatic cancer. A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer.
        N Engl J Med. 2004; 350 (Erratum in: N Engl J Med. 2004;351(7):726): 1200-1210
        • Chauffert B
        • Mornex F
        • Bonnetain F
        • et al.
        Phase III trial comparing intensive induction chemoradiotherapy (60 Gy, infusional 5-FU and intermittent cisplatin) followed by maintenance gemcitabine with gemcitabine alone for locally advanced unresectable pancreatic cancer. Definitive results of the 2000-01 FFCD/SFRO study.
        Ann Oncol. 2008; 19: 1592-1599
        • Loehrer PJ Sr
        • Feng Y
        • Cardenes H
        • et al.
        Gemcitabine alone versus gemcitabine plus radiotherapy in patients with locally advanced pancreatic cancer: an Eastern Cooperative Oncology Group trial.
        J Clin Oncol. 2011; 29: 4105-4112
        • Conroy T
        • Desseigne F
        • Ychou M
        • et al.
        Groupe tumeurs digestives of unicancer; PRODIGE Intergroup. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer.
        N Engl J Med. 2011; 364: 1817-1825
        • Conroy T
        • Castan F
        • Lopez A
        • et al.
        Five-year outcomes of FOLFIRINOX vs gemcitabine as adjuvant therapy for pancreatic cancer: a randomized clinical trial.
        JAMA Oncol. 2022; 8: 1571-1578
        • Mahaseth H
        • Brutcher E
        • Kauh J
        • et al.
        Modified FOLFIRINOX regimen with improved safety and maintained efficacy in pancreatic adenocarcinoma.
        Pancreas. 2013; 42: 1311-1315
        • Stein S.
        • James E.
        • Deng Y.
        • et al.
        Final analysis of a phase II study of modified FOLFIRINOX in locally advanced and metastatic pancreatic cancer.
        Br J Cancer. 2016; 114: 737-743
      4. Tempero MA, Pelzer U, O'Reilly EM, Winter J, Oh DY, Li CP, Tortora G, Chang HM, Lopez CD, Bekaii-Saab T, Ko AH, Santoro A, Park JO, Noel MS, Frassineti GL, Shan YS, Dean A, Riess H, Van Cutsem E, Berlin J, Philip P, Moore M, Goldstein D, Tabernero J, Li M, Ferrara S, Le Bruchec Y, Zhang G, Lu B, Biankin AV, Reni M; APACT Investigators. Adjuvant nab-Paclitaxel + Gemcitabine in Resected Pancreatic Ductal Adenocarcinoma: Results From a Randomized, Open-Label, Phase III Trial. J Clin Oncol. 2022 Dec 15:JCO2201134. doi:10.1200/JCO.22.01134. Epub ahead of print. PMID: 36521097.

      5. Abrams RA, Winter KA, Safran H, Goodman KA, Regine WF, Berger AC, Gillin MT, Philip PA, Lowy AM, Wu A, DiPetrillo TA, Corn BW, Seaward SA, Haddock MG, Song S, Jiang Y, Fisher BJ, Katz AW, Mehta S, Willett CG, Crane CH. Results of the NRG Oncology/RTOG 0848 Adjuvant Chemotherapy Question-Erlotinib+Gemcitabine for Resected Cancer of the Pancreatic Head: A Phase II Randomized Clinical Trial. Am J Clin Oncol. 2020 Mar;43(3):173–179. doi:10.1097/COC.0000000000000633. PMID: 31985516; PMCID: PMC7280743.

        • Hazard L
        • Tward JD
        • Szabo A
        • Shrieve DC.
        Radiation therapy is associated with improved survival in patients with pancreatic adenocarcinoma: results of a study from the surveillance, epidemiology, and end results (SEER) registry data.
        Cancer. 2007; 110: 2191-2201
        • Kooby DA
        • Gillespie TW
        • Liu Y
        • et al.
        Impact of adjuvant radiotherapy on survival after pancreatic cancer resection: an appraisal of data from the national cancer data base.
        Ann Surg Oncol. 2013; 20: 3634-3642
        • Rutter CE
        • Park HS
        • Corso CD
        • et al.
        Addition of radiotherapy to adjuvant chemotherapy is associated with improved overall survival in resected pancreatic adenocarcinoma: an analysis of the national cancer data base.
        Cancer. 2015; 121: 4141-4149
        • Torgeson A
        • Tao R
        • Garrido-Laguna I
        • Willen B
        • Dursteler A
        • Lloyd S.
        Large database utilization in health outcomes research in pancreatic cancer: an update.
        J Gastrointest Oncol. 2018; 9: 996-1004
        • Bernard ME
        • Sutera PA
        • Iarrobino NA
        • et al.
        Initial results of a prospective study of adjuvant pancreatic stereotactic body radiation therapy for close or positive margins.
        Adv Radiat Oncol. 2018; 4: 294-301
      6. Colin S. Hill, Eric Lutz, Elizabeth Jaffee, et al. Adjuvant allogeneic GM-CSF-transduced pancreatic tumor cell vaccine and low dose cyclophosphamide in a high-risk cohort of resected pancreatic cancer with SBRT and FFX. Manuscript in preparation. 2023

        • Neoptolemos JP
        • Palmer DH
        • Ghaneh P
        • et al.
        Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomized, phase 3 trial.
        Lancet. 2017; 389: 1011-1024
        • Merkow RP
        • Bilimoria KY
        • Tomlinson JS
        • et al.
        Postoperative complications reduce adjuvant chemotherapy use in resectable pancreatic cancer.
        Ann Surg. 2014; 260: 372-377
        • Wu W
        • He J
        • Cameron JL
        • et al.
        The impact of postoperative complications on the administration of adjuvant therapy following pancreaticoduodenectomy for adenocarcinoma.
        Ann Surg Oncol. 2014; 21: 2873-2881
      7. Labori KJ, Katz MH, Tzeng CW, Bjørnbeth BA, Cvancarova M, Edwin B, Kure EH, Eide TJ, Dueland S, Buanes T, Gladhaug IP. Impact of early disease progression and surgical complications on adjuvant chemotherapy completion rates and survival in patients undergoing the surgery first approach for resectable pancreatic ductal adenocarcinoma - A population-based cohort study. Acta Oncol. 2016;55(3):265-77. doi:10.3109/0284186X.2015.1068445. Epub 2015 Jul 25. PMID: 26213211.Labori KJ, Katz MH, Tzeng CW, et al: Impact of early disease progression and surgical complications on adjuvant chemotherapy completion rates and survival in patients undergoing the surgery first approach for resectable pancreatic ductal adenocarcinoma: a population-based cohort study.

        • Hall WA
        • Dawson LA
        • Hong TS
        • et al.
        Value of neoadjuvant radiation therapy in the management of pancreatic adenocarcinoma.
        J Clin Oncol. 2021; 39: 3773-3777
      8. Davendra Sohal, Mai T. Duong, Syed A. Ahmad, Namita Gandhi, Muhammad Shaalan Beg, Andrea Wang-Gillam, James Lloyd Wade, Elena Gabriela Chiorean, Katherine A Guthrie, Andrew M. Lowy, Philip Agop Philip, and Howard S. Hochster SWOG S1505: Results of perioperative chemotherapy (peri-op CTx) with mfolfirinox versus gemcitabine/nab-paclitaxel (Gem/nabP) for resectable pancreatic ductal adenocarcinoma (PDA).Journal of Clinical Oncology 2020 38:15_suppl, 4504

        • Ahmad SA
        • Duong M
        • Sohal DPS
        • et al.
        Surgical outcome results from SWOG S1505: a randomized clinical trial of mFOLFIRINOX versus Gemcitabine/Nab-paclitaxel for perioperative treatment of resectable pancreatic ductal adenocarcinoma.
        Ann Surg. 2020; 272: 481-486
        • Chawla A
        • Ferrone CR.
        Surgeon-led clinical trials in pancreatic cancer.
        Surg Oncol Clin N Am. 2023; 32: 143-151
        • Evans DB
        • Varadhachary GR
        • Crane CH
        • et al.
        Neoadjuvant gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head.
        J Clin Oncol. 2008; 26: 3496-3502
        • Murphy JE
        • Wo JY
        • Ryan DP
        • et al.
        Total neoadjuvant therapy with FOLFIRINOX followed by individualized chemoradiotherapy for borderline resectable pancreatic adenocarcinoma: a phase 2 clinical trial.
        JAMA Oncol. 2018; : 963-969
        • Tsai S
        • Christians KK
        • George B
        • et al.
        A phase II clinical trial of molecular profiled neoadjuvant therapy for localized pancreatic ductal adenocarcinoma.
        Ann Surg. 2018; 268: 610-619
        • Katz MH
        • Shi Q
        • Ahmad SA
        • et al.
        Neoadjuvant modified FOLFIRINOX treatment followed by capecitabine-based chemoradiation for borderline resectable pancreatic cancer: Alliance for clinical trials in oncology trial A021101.
        JAMA Surg. 2016; 151e161137
        • Kharofa J
        • Mierzwa M
        • Olowokure O
        • et al.
        Pattern of marginal local failure in a phase II trial of neoadjuvant chemotherapy and stereotactic body radiation therapy for resectable and borderline resectable pancreas cancer.
        Am J Clin Oncol. 2019; 42: 247-252
        • Jang JY
        • Han Y
        • Lee H
        • et al.
        Oncological Benefits of neoadjuvant chemoradiation with gemcitabine versus upfront surgery in patients with borderline resectable pancreatic cancer: a prospective, randomized, open-label, multicenter phase 2/3 trial.
        Ann Surg. 2018; 268: 215-222
        • Versteijne E
        • van Dam JL
        • Suker M
        • et al.
        Dutch pancreatic cancer group. neoadjuvant chemoradiotherapy versus upfront surgery for resectable and borderline resectable pancreatic cancer: long-term results of the Dutch randomized PREOPANC Trial.
        J Clin Oncol. 2022; 40: 1220-1230
        • Herman JM
        • Chang DT
        • Goodman KA
        • et al.
        Phase 2 multi-institutional trial evaluating gemcitabine and stereotactic body radiotherapy for patients with locally advanced unresectable pancreatic adenocarcinoma.
        Cancer. 2015; 121: 1128-1137
        • Teriaca MA
        • Loi M
        • Suker M
        • Eskens FALM
        • van Eijck CHJ
        • Nuyttens J.J.
        A phase II study of stereotactic radiotherapy after FOLFIRINOX for locally advanced pancreatic cancer (LAPC-1 trial): long-term outcome.
        Radiotherapy Oncol. 2020;
        • Katz MHG
        • Shi Q
        • Meyers JP
        • et al.
        Alliance A021501: Neoadjuvant mFOLFIRINOX or mFOLFIRINOX plus hypofractionated radiation therapy (RT) for borderline resectable (BR) adenocarcinoma of the pancreas.
        J Clin Oncol. 2021; 39 (_suppl): 377
      9. Pawlik TM, Laheru D, Hruban RH, Coleman J, Wolfgang CL, Campbell K, Ali S, Fishman EK, Schulick RD, Herman JM; Johns Hopkins Multidisciplinary Pancreas Clinic Team. Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer. Ann Surg Oncol. 2008 Aug;15(8):2081-8. doi: 10.1245/s10434-008-9929-7. Epub 2008 May 7. PMID: 18461404; PMCID: PMC2907242.

        • Hill C
        • Sehgal S
        • Fu W
        • et al.
        High local failure rates despite high margin-negative resection rates in a cohort of borderline resectable and locally advanced pancreatic cancer patients treated with stereotactic body radiation therapy following multi-agent chemotherapy.
        Cancer Med. 2022; 11: 1659-1668
        • Mellon EA
        • Hoffe SE
        • Springett GM
        • et al.
        Long-term outcomes of induction chemotherapy and neoadjuvant stereotactic body radiotherapy for borderline resectable and locally advanced pancreatic adenocarcinoma.
        Acta Oncol. 2015; 54: 979-985
        • Koay EJ
        • Katz MHG
        • Wang H
        • et al.
        Computed tomography-based biomarker outcomes in a prospective trial of preoperative FOLFIRINOX and chemoradiation for borderline resectable pancreatic cancer.
        JCO Precis Oncol. 2019; 23
        • Koay EJ
        • Zaid M
        • Aliru M
        • et al.
        Nab-Paclitaxel, capecitabine, and radiation therapy after induction chemotherapy in treating patients with locally advanced and borderline resectable pancreatic cancer: phase 1 trial and imaging-based biomarker validation.
        Int J Radiat Oncol Biol Phys. 2022; 114: 444-453
        • Hammel P
        • Huguet F
        • van Laethem JL
        • et al.
        LAP07 trial group. effect of chemoradiotherapy vs chemotherapy on survival in patients with locally advanced pancreatic cancer controlled after 4 months of gemcitabine with or without erlotinib: the LAP07 randomized clinical trial.
        JAMA. 2016; 315: 1844-1853
        • Cardillo N
        • Seible DM
        • Fero KE
        • et al.
        Clinical impact of local progression in pancreatic cancer.
        J Natl Compr Canc Netw. 2018; 16: 711-717
        • Philip PA
        • Lacy J
        • Portales F
        • et al.
        Nab-paclitaxel plus gemcitabine in patients with locally advanced pancreatic cancer (LAPACT): a multicentre, open-label phase 2 study.
        Lancet Gastroenterol Hepatol. 2020; 5: 285-294
        • Murphy JE
        • Wo JY
        • Ryan DP
        • et al.
        Total neoadjuvant therapy with FOLFIRINOX in combination with losartan followed by chemoradiotherapy for locally advanced pancreatic cancer: a phase 2 clinical trial.
        JAMA Oncol. 2019; 5: 1020-1027
        • Hill CS
        • Rosati L
        • Wang H
        • et al.
        Multi-agent chemotherapy and stereotactic body radiation therapy in patients with unresectable pancreatic adenocarcinoma: a prospective nonrandomized controlled trial.
        Pract Radiat Oncol. 2022; S1879-8500: 00072-00078
        • Gemenetzis G
        • Groot VP
        • Blair AB
        • et al.
        Survival in locally advanced pancreatic cancer after neoadjuvant therapy and surgical resection.
        Ann Surg. 2019; 270: 340-347
        • Ferrone CR
        • Marchegiani G
        • Hong TS
        • et al.
        Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer.
        Ann Surg. 2015; 261: 12-17
        • Truty MJ
        • Kendrick ML
        • Nagorney DM
        • et al.
        Factors predicting response, perioperative outcomes, and survival following total neoadjuvant therapy for borderline/locally advanced pancreatic cancer.
        Ann Surg. 2021; 273: 341-349
        • Faris JE
        • Blaszkowsky LS
        • McDermott S
        • et al.
        FOLFIRINOX in locally advanced pancreatic cancer: the Massachusetts General Hospital Cancer Center experience.
        Oncologist. 2013; 18: 543-548
        • Rainer F
        • Michael G
        • Robert G
        • et al.
        Randomized phase III trial of induction chemotherapy followed by chemoradiotherapy or chemotherapy alone for nonresectable locally advanced pancreatic cancer: First results of the CONKO-007 trial.
        J Clin Oncol. 2022; 40 (_suppl): 4008
        • Arscott WT
        • Nead KT
        • Bear A
        • et al.
        Concurrent nab-paclitaxel and radiotherapy: novel radiosensitization for borderline resectable or unresectable pancreatic cancer.
        Am J Clin Oncol. 2021; 44: 469-474
        • Krishnan Sunil
        • Chadha A
        • Yelin S
        • et al.
        Focal radiation therapy dose escalation improves overall survival in locally advanced pancreatic cancer patients receiving induction chemotherapy and consolidative chemoradiation.
        Int J Radiation Oncol Biol Phys. 2016; 94: 755-765
        • Rudra S
        • Jiang N
        • Rosenberg SA
        • et al.
        Using adaptive magnetic resonance image-guided radiation therapy for treatment of inoperable pancreatic cancer.
        Cancer Med. 2019; 8: 2123-2132
        • Koay EJ
        • Hanania AN
        • Hall WA
        • et al.
        Dose-escalated radiation therapy for pancreatic cancer: a simultaneous integrated boost approach.
        Pract Radiat Oncol. 2020; 10: e495-e507
        • Chuong MD
        • Bryant J
        • Mittauer KE
        • et al.
        Ablative 5-fraction stereotactic magnetic resonance-guided radiation therapy with on-table adaptive replanning and elective nodal irradiation for inoperable pancreas cancer.
        Pract Radiat Oncol. 2021; 11: 134-147
        • Hall WA
        • Small C
        • Paulson E
        • et al.
        Magnetic resonance guided radiation therapy for pancreatic adenocarcinoma, advantages, challenges, current approaches, and future directions.
        Front Oncol. 2021; 11628155
      10. Accessed July 15, Available at:
        • Harrison JM
        • Wo JY
        • Ferrone CR
        • et al.
        Intraoperative radiation therapy (IORT) for borderline resectable and locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC) in the era of modern neoadjuvant treatment: short-term and long-term outcomes.
        Ann Surg Oncol. 2020; 27: 1400-1406
        • Lee YS
        • Kim HS
        • Cho Y
        • et al.
        Intraoperative radiation therapy induces immune response activity after pancreatic surgery.
        BMC Cancer. 2021; 21: 1097
        • Reddy AV
        • Hill CS
        • Zheng L
        • He J
        • Narang AK.
        A safety study of intraoperative radiation therapy following stereotactic body radiation therapy and multi-agent chemotherapy in the treatment of localized pancreatic adenocarcinoma: study protocol of a phase I trial.
        Radiat Oncol. 2022; 17: 173
        • Okoro CM
        • Schüler E
        • Taniguchi CM.
        The therapeutic potential of FLASH-RT for pancreatic cancer.
        Cancers (Basel). 2022; 14: 1167
        • Koay EJ
        • Hall W
        • Park PC
        • Erickson B
        • Herman JM.
        The role of imaging in the clinical practice of radiation oncology for pancreatic cancer.
        Abdom Radiol (NY). 2018; 43: 393-403
        • Hoffe S
        • Frakes JM
        • Aguilera TA
        • et al.
        Randomized, double-blinded, placebo-controlled multicenter adaptive phase 1-2 Trial of GC 4419, a dismutase mimetic, in combination with high dose stereotactic body radiation therapy (SBRT) in locally advanced pancreatic cancer (PC).
        Int J Radiat Oncol Biol Phys. 2020; 108: 1399-1400
        • Schneider M
        • Strobel O
        • Hackert T
        • Büchler MW.
        Pancreatic resection for cancer-the Heidelberg technique.
        Langenbecks Arch Surg. 2019; 404: 1017-1022
        • Hackert T
        • Strobel O
        • Michalski CW
        • et al.
        The TRIANGLE operation – radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single arm observational study.
        HPB (Oxford). 2017; 19: 1001-1007
        • Nagakawa Y
        • Yi SQ
        • Takishita C
        • et al.
        Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer.
        J Hepatobiliary Pancreat Sci. 2020; 27: 342-351
        • Hill CS
        • Fu W
        • Hu C
        • et al.
        Location, location, location: what should be targeted beyond gross disease for localized pancreatic ductal adenocarcinoma? Proposal of a standardized clinical tumor volume for pancreatic ductal adenocarcinoma of the head: the “Triangle Volume.
        Pract Radiat Oncol. 2022; 12: 215-225
        • Miller JA
        • Toesca DAS
        • Baclay JRM
        • et al.
        Pancreatic stereotactic body radiation therapy with or without hypofractionated elective nodal irradiation.
        Int J Radiat Oncol Biol Phys. 2022; 112: 131-142
        • Nakamura A
        • Prichard HA
        • Wo JY
        • Wolfgang JA
        • Hong TS.
        Elective nodal irradiation with simultaneous integrated boost stereotactic body radiotherapy for pancreatic cancer: Analyses of planning feasibility and geometrically driven DVH prediction model.
        J Appl Clin Med Phys. 2019; 20: 71-83
        • Reddy AV
        • Hill CS
        • Sehgal S
        • et al.
        Impact of somatic mutations on clinical and pathologic outcomes in borderline resectable and locally advanced pancreatic cancer treated with neoadjuvant chemotherapy and stereotactic body radiotherapy followed by surgical resection.
        Radiat Oncol J. 2021; 39: 304-314
        • Encarnación-Rosado J
        • Kimmelman AC.
        Harnessing metabolic dependencies in pancreatic cancers.
        Nat Rev Gastroenterol Hepatol. 2021; 18: 482-492
        • Hwang R.F.
        • Moore T.
        • Arumugam T.
        • et al.
        Cancer-associated stromal fibroblasts promote pancreatic tumor progression.
        Cancer Res. 2008; 68: 918-926