Stereotactic radiotherapy of pancreatic cancer: a systematic review on pain relief

Abstract

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.

Stereotactic body radiotherapy vs conventionally fractionated chemoradiation in locally advanced pancreatic cancer: A multicenter case‐control study (PAULA‐1)

“…Moreover considering that in most cases LAPC treatment has a palliative purpose, these studies should include an accurate assessment of quality of life and symptoms control, especially in terms of pain relief. In fact, both conventional radiotherapy 26 and SBRT 27 are able to improve this symptom but direct comparisons of their relative effectiveness are lacking. Finally, considering that the only possibility of cure for patients with LAPC is to achieve a tumor downstaging to allow a radical surgical resection, the rate of resectability after SBRT and CRT should represent another relevant end point.…”

Higher Biologically Effective Dose Predicts Survival in SBRT of Pancreatic Cancer: A Multicentric Analysis (PAULA-1)

“…Our report showed wide inhomogeneity in SBRT of LAPC (in terms of dose, fractionation, and technique), probably attributable to the lack of guidelines in this setting. However, data about tolerability, pain relief (34), and outcomes suggest that SBRT can be considered as a treatment option in clinical practice.…”

Basics and Frontiers on Pancreatic Cancer for Radiation Oncology: Target Delineation, SBRT, SIB Technique, MRgRT, Particle Therapy, Immunotherapy and Clinical Guidelines

“…These GLs do not recommend a specific RT regimen but suggest a personalized approach based on patient and tumor characteristics [3,28,30,31]. Among the few evidence on pain control achieved with RT in this setting, we can report a 75% rate of pain relief recorded in a small series of patients treated with 30 Gy in 10 fractions with standard techniques [59] and an 85% pooled response rate after SBRT, as reported in a systematic review [60].…”