Bölüm
7
PANKREAS KANSERİNDE NEOADJUVAN RADYOTERAPİNİN YERİ
Melek AKÇAY
1GİRİŞ
Pankreas kanseri, kansere bağlı ölümlerin dördüncü önde gelen nedenidir (1).
Günümüzde cerrahi tedavi, tek küratif seçenek olmakla birlikte, hastaların yalnız- ca %10-20’si tanı anında operabıldır. Lokalize hastalığı olan vakalara bile 5 yıllık sağkalım oranı yaklaşık %20’dir (2). Bu oran, tam rezeksiyon yapılan ve nod nega- tif vakalarda daha yüksektir (3). Unrezektabl lokal ileri evre hastalıkta ise medyan sağkalım 8-14 aydır. Tanı anında, %60 metastatik hastalığa sahiptir ve medyan sağkalım 4-12 aydır (4). Pankreas kanseri için küratif rezeksiyon uygulandıktan sonra bile, hastaların %80-85’i nüks eder. Pozitif cerrahi sınır ve nodal hastalık, bu nüks oranını %90’a yükseltir (5,6). Neoadjuvan tedavinin kullanılması, çeşitli ne- denlerle bu rakamları iyileştirmek için alternatif bir yaklaşım sunar. Bu nedenler;
1- Hastaların yaklaşık üçte biri rezeksiyon sonrası adjuvan tedavide önemli bir gecikme yaşar ya da adjuvan tedavi alamaz (7,8).
2- Metastatik hastalıkları neoadjuvan tedavi sırasında klinik olarak belirgin hale geldiği için, hastaların %20 ile %40’ı rezeksiyon morbiditesinden korunacak- tır (9,10).
3- Preoperatif tedavi, teorik olarak daha az toksik ve daha etkili olabilir. Cerrahi sonrası, radyasyon alanında ince barsak volümü daha fazla olup, oksijenizas- yon azalmış olacaktır. Oksijenzasyonun azalmış olması, tümör yatağına ilaç iletimini de azaltacaktır (11,12).
4- Lokal, borderline ve unrezektabl tümörü olan hastalarda, cerrahi rezeksiyonu ve cerrahi bölgenin sterilizasyonunu ve R0 rezeksiyonu potansiyel olarak ko- laylaştıracak ve cerrahi manipülasyon sırasında yayılma riskini azaltacaktır.
1 Doktor Öğretim Üyesi, Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Radyasyon Onkolojisi ABD, mcak- cay@ogu.edu.tr
Sonuç:
Pankreas kanseri, kansere bağlı ölümlerin dördüncü önde gelen nedenidir.
Cerrahi tedavi, tek küratif seçenek olmakla birlikte, hastaların yalnızca %10-20’si tanı anında operabıldır. Lokalize hastalığı olan vakalarda bile 5 yıllık sağkalım oranı yaklaşık %20 iken bu oran, komplet rezeksiyon yapılan ve nod negatif va- kalarda daha yükseltir. Neoadjuvan KRT; lokal, borderline ve unrezektabl tümörü olan hastalarda, cerrahi rezeksiyonu ve cerrahi bölgenin sterilizasyonunu ve R0 rezeksiyonu potansiyel olarak kolaylaştıracak ve cerrahi manipülasyon sırasında yayılma riskini azaltacaktır. Lokal kontrol ve sağkalım açısından R0 rezeksiyonun önemi göz önüne alındığında lokal ileri evre pankreas kanserinde neaodjuvan KRT standart, tedavi olarak düşünülmelidir.
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