The Locally Advanced Nonmetastatic Cancer

At the time of diagnosis, around 20% of patients present with a resectable tumor, 50% with a metastatic disease, and 30% with a locally advanced tumor, unresectable because of superior mesenteric artery (SMA) or celiac encasement but nonmetastatic. Despite advances in chemoradiation (CRT) and improved systemic chemotherapeutic agents, those who present with locally advanced disease suffer both from high rates of distant metastatic failure and local progression, with median survival time ranging from 5 to 11 months. In the past 30 years, modest improvements in median survival have been attained for patients with locally advanced tumors treated by CRT or chemotherapy (CT) protocols. However, no significant impact on long-term survival has been accomplished. Optimal therapy for patients with locally advanced pancreatic carcinoma remains controversial. A recent systematic review concluded that there is no standard for the treatment of locally advanced pancreatic cancers, but two options: gemcitabine-based CT or CRT. These approaches are complementary and both should be considered. An induction CT followed by a CRT for nonprogressive patients is a promising strategy whose validation is ongoing in a phase III trial.