In light of the recently published Alliance A021501 trial, what is your approach to incorporating SBRT for the treatment of borderline resectable pancreatic cancer?

My approach is the same as it always has been. I have never used low-dose small volume "SBRT" for BRPC or LAPC because it does not make sense. Treating an infiltrating neurotropic tumor that spreads along arteries with millimeter margins on the gross tumor and leaving the regional lymph nodes untreated when they are involved 80% of the time leads to local tumor control in only half of the volume. Not surprisingly, 50% of patients suffer locoregional failure outside of this "SBRT" volume.

(Zhu, et al, IJROBP 2019)

This treatment is a flagrant violation of the first principles of radiation oncology. Preoperative radiation treatment should treat wide margins and regional nodes, not the same or less margin than the surgeon uses. I am not surprise...