Locally advanced pancreatic carcinoma (LAPC) has a poor prognosis and the purpose of treatment is survival prolongation and symptom palliation. Radiotherapy has been reported to reduce pain in LAPC. Stereotactic RT (SBRT) is considered as an emerging radiotherapy technique able to achieve high local control rates with acceptable toxicity. However, its role in pain palliation is not clear. To review the impact on pain relief with SBRT in LAPC patients, a literature search was performed on PubMed, Scopus, and Embase (January 2000–December 2017) for prospective and retrospective articles published in English. Fourteen studies (479 patients) reporting the effect of SBRT on pain relief were finally included in this analysis. SBRT was delivered with both standard and/or robotic linear accelerators. The median prescribed SBRT doses ranged from 16.5 to 45 Gy (median: 27.8 Gy), and the number of fractions ranged from 1 to 6 (median: 3.5). Twelve of the 14 studies reported the percentage of pain relief (in patients with pain at presentation) with a global overall response rate (complete and partial response) of 84.9% (95% CI, 75.8%–91.5%), with high heterogeneity (Q2 test: P<0.001; I2=83.63%). All studies reported toxicity data. Acute and late toxicity (grade ≥3) rates were 3.3%–18.0% and 6.0%–8.2%, respectively. Reported gastrointestinal side effects were duodenal obstruction/ulcer, small bowel obstruction, duodenal bleeding, hemorrhage, and gastric perforation. SBRT achieves pain relief in most patients with pancreatic cancer with an acceptable gastrointestinal toxicity rate. Further prospective studies are needed to define optimal dose/fractionation and the best systemic therapies modality integration to reduce toxicity and improve the palliative outcome. Finally, the quality of life and, particularly, pain control should be considered as an endpoint in all future trials on this emerging treatment technique.

Aim: The purpose of the present multicentric study was to review stereotactic body radiotherapy (SBRT) with or without chemotherapy (CHT) experience in locally advanced pancreatic cancer (LAPC). Endpoints were overall survival (OS), local control (LC), and distant metastasis-free survival (DMFS). Several parameters' impact on these outcomes was assessed. Materials and Methods: Fifty-six patients with LAPC undergoing SBRT+/-CHT were included. SBRT median BED α/β10Gy was 48.0 Gy (range=28.0-78.7). Survival curves were calculated by Kaplan-Meier method. A Cox regression model was fitted. Results: At a median follow-up of 15.0 months, 2-year OS, LC, DMFS were: 33.8% 55.4%, and 22.9%, respectively. Patients treated with BED α/β10Gy ≥48 Gy showed improved OS (p=0.020) and LC (p=0.024). At multivariate analysis, BED α/β10Gy ≥48 Gy was significantly associated to both higher OS (p=0.042) and LC (p=0.045), while post-SBRT CHT improved DMFS (p=0.003). Conclusion: SBRT proved to be tolerable and effective in LAPC. Moreover, BED α/β10Gy ≥48 Gy was significantly correlated with improved OS and LC. Pancreatic cancer (Pca) is projected to become the second cancer killer in the United States by 2030 (1). Overall, 5-year survival in Pca patients is only 8% (2). Radical surgery achieving negative margins is the only treatment able to gain long-term survival (3, 4). Unfortunately, only a small percentage of patients (around 20%) present with a resectable tumor at diagnosis, while 30-40% of them have unresectable locally advanced disease (5). Moreover, these patients represent a category with an intermediate prognosis between resectable and metastatic disease (6), with a median overall survival (OS) ranging from 9 to 11 months (5). Nowadays, a therapeutic standard approach for Pca is missing and therefore the treatment is frequently institution 465 This article is freely accessible online.

Although the rate of severe toxicity was very low, the real impact of WLI on patients' outcomes remains unproven, probably due to the narrow dose limits that can be delivered to the whole lung parenchyma. New strategies to prevent or treat lung metastases in these patients should be tested. Ultra-fractionated radiotherapy concurrent with modern chemotherapy protocols could be tested in this setting due to the chemo-sensitizing effect and negligible radio-induced toxicity of fraction doses <0.5 Gy.