Approximately 25% of patients diagnosed with pancreatic cancer present with non-metastatic resectable or borderline resectable disease. Preoperative radiotherapy would improve local-regional control, and when preoperative radiotherapy delivered with protons, significant bowel and gastric tissue-sparing is achieved and clinical outcomes indicate that proton therapy does not increase the risk of operative complications nor extend the length of the procedure.

Providing the outcomes of a series of 5 patients who received high-dose proton radiotherapy as definitive treatment for unresectable disease who were ultimately able to undergo pancreatectomy, the authors argued that preoperative radiotherapy directed to gross disease and regional lymphatic beds at high risk of harboring microscopic disease appears to be an oncologically rational intervention to reduce this risk, and that proton-based preoperative radiotherapy should be considered for patients with resectable and borderline resectable disease.