Background: The role of adjuvant radiotherapy (adj-XRT) for patients with margin-negative (R0), node-positive (N+) pancreatic adenocarcinoma (PDAC) after pancreaticoduodenectomy (PD) remains controversial. This study assessed the impact of adj-XRT on overall survival (OS) for PDAC patients who underwent R0N+ PD.
Methods: The study queried a national database to identify R0N+ (stage IIB-III) patients who underwent PD for PDAC between 2004 and 2019. Propensity score-matching, based on a multivariate regression model predicting the use of adj-XRT, was used to match patients who received adj-XRT with those who did not.
Results: The study analyzed a cohort of 20,974 patients with 51.2% male (n = 10,735) and 81.7% white (n = 17,144) patients. The mean age was 65.5 ± 9.8 years. Of these patients, 92.8% (n = 18,008) had stage IIB and 7.2% (n = 1407) had stage-III disease. The median OS for the overall cohort was 25.1 months (range, 14.1-48.3) months. The patients in the adj-XRT cohort were younger (63.8 ± 9.6 vs 66.3 ± 9.8 years; p < 0.001) and predominantly male (52.7% vs 50.4%; p = 0.002), with a Charlson-Deyo score of 1 or lower (92.4% vs 89.5%; p < 0.001. After propensity score-matching, the matched cohorts were similar with respect to patient age, race, sex, location, Charlson-Deyo score, and stage of disease (all p > 0.050). The patients who received adj-XRT had better median OS (26.0 months [range, 13.7-47.6 months] vs 24.1 months [range, 15.6-53.1 months]; p < 0.001). Adj-XRT was associated with improved median OS (26.0 months [range, 15.6-53.4 months] vs 24.0 months [range, 13.7-47.6 months]; p < 0.001) in stage IIB, but not in stage III (median, 25.7 months [range, 15.4-45.4 months] vs 25.5 months [range, 13.9-41.1 months]) patients.
Conclusions: Adj-XRT after R0N+ PD is associated with a modest survival benefit for stage IIB patients, but showed no difference for patients with advanced locoregional PDAC.
© 2026. Society of Surgical Oncology.