70 years male retired executive presented with complaints of Abdominal  pain one month

loss of appetite for a year

H/o vomitting on and off.

He is diabetic .He consulted for the same else where . Was jaundiced and was diagnosed to have a carcinoma of the uncinate process of the pancreas adenocarcinoma ductal carcinoma grade 3 . Biliary stenting was done following which jaundice settled .

He was advised radical surgery . PETCT  revealed mass involving uncinate process of pancreas infiltrating the duodenum and distal CBD and portal vein . No regional or distant metastasis.

Patient was unwilling for radical surgery .

MDT Medical oncologist and Radiation oncologist

Participated in clinical discussion

Two options were offered to the patient .

A cource of combination chemotherapy including gemcitabine and .followed by sequential local focused Radiotherapy .

Explaining duely the proable toxicities of chemotherapy.

And the second option only radiotherapy Image guided intensity modulated radiation with conventional fractionation radiotherapy.

However the role of SBRT is a possibility in this case.

For its advantages of shorter  course of treatment and the enhanced tumour control with hypofractionated doses.

The presence of stent and the closeness of duodenum tumour nearly abbuting the CBD and portal vein could perpetuate unwanted toxicities at these normal tissues .

The patient having listened to the pros and cons of treatment outcome and adverse events after discussion among their family members decided to go for radiation with concurrent oral capacitabine.

Started on treatment.

With IGIMRT at daily fractionation of 1.8Gy to GTV gross tumour volume upto 45 Gy in 25 days .

Along with oral capacitabine .