Imaging-guided SMART improves survival in locally advanced and borderline resectable pancreatic cancer: a comparative study

Pancreatic cancer remains notoriously challenging to treat due to its aggressive nature and complex anatomic location. Late-stage diagnoses often result in high mortality rates. This study assesses the effectiveness of combining ablative stereotactic MRI-guided intensity-modulated radiation therapy (SMART) with chemotherapy for treating locally advanced and borderline resectable pancreatic cancer. We retrospectively analyzed 235 pancreatic cancer patients treated between 2020 and 2023. Patients were divided into chemoradiation (SMART + chemotherapy, n = 106) and chemotherapy-only (n = 129) groups. Key outcomes included progression-free survival, overall survival, margin-negative resection rates, lymphovascular invasion, and toxicities. The chemoradiation group demonstrated improved PFS (8.30 ± 1.20 vs. 7.90 ± 1.30 months, P = 0.015) and OS (14.30 ± 2.60 vs. 13.50 ± 2.40 months, P = 0.015), with higher rates of margin-negative resections (92.45% vs. 80.62%, P = 0.009) and reduced LVI (37.74% vs. 52.71%, P = 0.022) compared to chemotherapy alone. However, acute toxicities, including fatigue and abdominal pain, were more frequent in the chemoradiation group. Locoregional control and distant metastasis-free survival showed no significant group differences (P > 0.05). Overall, SMART enhances local tumor control and survival outcomes in severe pancreatic cancer, albeit with increased acute toxicity.