Robotic radiosurgery in pancreatic cancer: A systematic review

Table 1 Study and treatment characteristics

Ref.	Study design	Inclusion criteria	Simulation	PTV	Image guidance	Dose prescription	Radiotherapy dose, median (range)	% of patients receiving chemotherapy
Koong et al[17], 2004	Phase I	LA; < 7.5 cm1	Pancreatic protocol CT	NR	Fiducials tracking	To isodose surrounding PTV	20 Gy SF RRS	6.6 before RRS
Koong et al[18], 2005	Phase II	LA	Pancreatic protocol CT	NR	Mid-breath-hold or fiducials tracking	To isodose surrounding PTV	45 Gy in 1.8 Gy/fr (IMRT) +; 25 Gy SF RRS boost	100.0 concurrent to IMRT: 5-FU or CAP
Schellenberg et al[19], 2008	Case serie	LA	End-expiration biphasic CT + respiratory gated CT + PET-CT	PTV: GTV + 2-3 mm	Fiducials tracking	To isodose surrounding PTV	25 Gy SF RRS	100.0 1 cycle GEM pre-RRS; 0-8 cycles GEM post-RRS
Seo et al[20], 2009	Phase I	LA; no duodenal invasion; < 3 N+	CT + PET-CT (restricted respiratory motion)	PTV: GTV + 2 mm, or 4 mm cranio-caudally	Fiducials tracking	To isodose covering 97% of PTV	40 Gy in 2 Gy/fr (3D-CRT) + 16.5 Gy (14-17) SF RRS boost	70.0 (6 before RT; 15 concurrent to 3D-CRT)
Goyal et al[21], 2012	Case serie	LA	CT + MRI ± PET-CT	NR	Fiducial tracking	To 70% isodose	14 pts: 25 (20-25) SF RRS 5 pts: 3 fractions (24-30)	68% before RRS (various schedules)

¹Two patients received previous radiotherapy. 3D-CRT: 3D-conformal radiation therapy; 5-FU: 5-fluorouracil; GEM: Gemcitabine; GTV: Gross tumor volume; IMRT: Intensity modulated radiation therapy; LA: Locally advanced; NR: Not reported; PTV: Planning target volume; RRS: Robotic radiosurgery; SF: Single fraction.

Table 2 Patient and tumor characteristics

Ref.	Patients	Stage	Median GTV size (cm3); mean (range)	Site	Median follow-up (mo), range
Koong et al[17], 2004	15	NR	29 (19-72)	H: 66.6%, B: 26.6%, T: 6.6%	5.0
Koong et al[18], 2005	191	NR	50 (14-92)	H: 68%, B: 32%	5.4
Schellenberg et al[19], 2008	16	NR	PTV: 48 (21-84)	H: 87.5%, B: 12.5%	NR
Seo et al[20], 2009	30	T4: 100.0% N1: 30.0%	41 (21-96)	H: 56.7% B/T: 43.3%	14.5
Goyal et al[21], 2012	19	M1: 4 pts	57 (10-118)	NR	9 (5.8-23.1)

¹Sixteen patients received RRS. B: Body of the pancreas; H: Head of the pancreas; NR: Not reported; PTV: Planning target volume; T: Tail of the pancreas.

Table 3 Results

Ref.	Tumor response criteria	Tumor response (%)	Median overall survival (mo)	Local control	Toxicity scale	Grade 3-4toxicity
Koong et al[17], 2004	-	NR	11.0	LP: 20%1	RTOG	0%
Koong et al[18], 2005	-	NR	7.7; 1-yr: 15%	LP: 6.2%2	RTOG	Acute: Gastroparesis:10.5%3
Schellenberg et al[19], 2008	-	NR	11.4; 1 yr: 50%	LP: 19%	CTC 3.0	Acute: gastric ulcer: 6.2%; Late: duodenal stenosis: 6.2%; Duodenal perforation: 6.2%4
Seo et al[20], 2009	RECIST	68 (PR: 68)	14.0; 1 yr: 60%	LP: 44% LPFS (1-yr): 70.2 %;	RTOG	Acute: duodenal obstruction: 3.3%; Late: 0%
Goyal et al[21], 2012	RECIST	44 (CR: 13, PR: 31)	14.45; 1 yr: 56%	LPFS (1-yr): 65% LPFS (median): 11.4 mo	CTC 3.0	GI ulcer: 16%6

¹Local progressions: 0% in patients receiving 25 Gy;

²In patients receiving RRS;

³Unreported rate of late duodenal ulcers;

⁴Five duodenal ulcers were classified G2;

⁵14.8 mo in M0 patients;

⁶Asymptomatic pyloric ulcer: 5.7%. CR: Complete response; GI: Gastrointestinal; LP: Local progression; LPFS: Local progression free survival; NR: Not reported; PR: Partial response.