Updated 1 November 2005

Tumours that are seen to involve the celiac axis or the superior mesenteric vessels (stage III) cannot safely be resected. As a result, patients are treated palliatively according to their symptoms.

Patients with obstructive jaundice benefit from endoscopic biliary stent insertion. Percutaneous transhepatic biliary drainage is done if endoscopic stenting is not possible. Patients initially have an internal-external catheter that can be completely internalized in some patients.

Patients may have severe pain and should be given strong opioid analgesia, often in very high doses. Care to prevent and manage accompanying symptoms such as nausea and constipation is needed. Sometimes, a celiac nerve block or radiotherapy may be beneficial. Patients often benefit from a consultation with a physician specializing in pain and symptom management.

The optimal treatment for patients with locally advanced pancreas cancer remains controversial. There have been studies with chemoradiotherapy showing modest survival benefit (reviewed by Willet et al).(16) Randomized studies report two-year survival at 10% to 20% but at the cost of significant toxicity. Radiotherapy alone to small volume unresectable tumours is very well tolerated, and should be considered in otherwise fit patients for whom the potential toxicity of combined treatment is inappropriate. Small retrospective studies have reported improved 2 and 5 year survival figures. Palliative radiotherapy for locally advanced pancreatic cancers is sometimes indicated. The symptoms which show the highest response rate are pain, abdominal fullness and early satiety. External beam radiotherapy is not usually effective in resolving obstructive jaundice. Hypofractionated radiotherapy (e.g. 1600 cGy in 2 fractions separated by a week) or short courses of radiotherapy (e.g. 2000 cGy/5 fractions) with simply parallel opposed fields are well tolerated, though may cause transient nausea requiring antiemetics. Bulky metastatic disease to the liver causing pain often also responds well to hypofractionated radiotherapy.

In terms of chemotherapy on its own, gemcitabine (GIPGEM) is the most commonly used agent based upon the pivotal trial for metastatic disease where 26% of the patients in the study had locally advanced disease.(17) Patients should be enrolled in clinical trials whenever possible.