How Does Radiation Alleviate Celiac Plexus-Associated Pain?

During the 2026 Annual American College of Radiation Oncologists (ACRO) Summit, Michael Buckstein, MD, presented on the benefits and feasibility of using radiation to treat celiac plexus-associated pain. The presentation was based upon results from a phase 2 trial published in Lancet Oncology in August 2024.¹

Buckstein, a radiation oncologist, as well as an associate professor, assistant program director and vice chair for Education at Mount Sinai Hospital, spoke with CancerNetwork® at ACRO based on his presentation. The discussion underscored the importance of the topic and where this technique may hopefully evolve to in the next 5 years.

What was the rationale for your presentation on using radiation for celiac plexus-associated pain?

This presentation is for a large audience for a trial that was just published last year. The lead on that trial was Yaacov Lawrence, MA, MBBS, MRCP, from Israel, and it was a revolutionary trial in the sense of providing an important service in terms of treating pancreatic-related pain or celiac plexus-related pain. Its adoption [might be] limited [because] it's somewhat scary to do and somewhat challenging to do. This is just a great platform from ACRO, as they told me to publicize this to a larger audience. To hopefully help implement it in more individuals' clinics.

What are the key takeaways from your presentation?

There are 3 big takeaways. The first thing that every clinician knows is that celiac plexus-related cancer pain is a real thing. Honestly, anyone in practice who treats any kind of [gastrointestinal] malignancies knows this is a real thing and that the current standards that we have to treat it are not adequate. The second is that this novel, somewhat intimidating, but actually very easy to implement, radiation protocol using very high-dose radio surgery of 25 Gy in a single fraction was proven to be effective. It's quite easy to do. The third thing of the talk is that I try to walk the audience through some of the pitfalls in implementation: What are some of the problems that I had when I was doing this as part of the one of the centers enrolled in this protocol, and what they can do to hopefully help bring this to their patient and deliver this very important service to a very important clinical population.

What clinical characteristics or diagnostic findings help you identify which patients are candidates for this?

Everyone knows that pancreatic cancer presents with painless jaundice, but number 2 is the patient's hunched over. They have epigastric pain and pain radiating through the back. That's the tell-tale sign. They present with that and usually go through a series of clinical investigations, just ruling out the usual causes of epigastric pain, like [gastroesophageal reflux disease], and then it presents with that. The pain usually gets a little better with chemotherapy, and then just comes back. It always comes back, and it's present both in metastatic patients and in localized patients.

How do outcomes with this technique compare with other supportive measures?

The standards of care right now for celiac-related pain are usually narcotics. There's always some level of narcotics you can get to where a patient becomes pain-free, but it obviously comes at a huge cost of [adverse] effects. And then celiac plexus blocks, which are woefully inadequate in my experience, and I think in almost everyone's experience. This trial was a positive trial in the sense that it produced a reduction in a validated pain scale by a significant number of points. More than 50% of patients had a response to the therapy, and a reduction in opioid use at 6 weeks was significantly positive for patients who received the celiac plexus radiation block vs standard, and what we normally would expect in the standard population. It was very encouraging.

How do patients typically tolerate the procedure?

One of the beauties of the procedure was that it was well thought-out by this group in Israel who originated this protocol, in that they decided to do this in as few treatments as possible. The regional plan was 5, and they went down to 1. It involves just 2 visits for the patient. They have to come in for a simulation, and they have to come in for a treatment. They get heavily pre-medicated during that treatment and afterwards to minimize toxicity and [adverse] effects in the acute setting from that. Patients tolerate it quite well.

What’s your preferred radiation planning and delivery technique?

You have to use some type of modulated therapy. One of the biggest problems we had in the US and continue to have is that insurance companies still don't want to pay for it, so using the classic codes of [stereotactic radiosurgery] or [stereotactic body radiation therapy] is off the table at this point unless you have a very permissive insurance company. But you can use [intensity-modulated radiation therapy (IMRT)] codes. So if you're willing, you can convince your billing department that that's okay. You can deliver this with a single fraction of IMRT; the planning is the same, the setup is the same. You don't have to go crazy with 4D simulations and gating and the typical advanced radiation metrics that were not used for the majority of patients, and just treat. I think it can be done.

What operational challenges did you face when implementing this into your practice?

Quite frankly, the hardest one was insurance blockades. So these are patients who are sick; they have weeks or months to live usually, and you're offering them at least a potential treatment, and they are frustrated that they're not getting on the machine because the insurance companies are blocking it. Their referring physicians are getting frustrated. Everything was frustrating. It's gotten better since now we have a publication showing the positive results. It is in the NCCN guidelines at this point, so it'll make it much easier. But that was by far the number one in the frustration levels. Some of the technicalities of learning how to do it [were obstacles]. It's scary. Giving 25 Gy in a single fraction, whether you're doing the brain or anywhere, it's a very serious dose. But the way the protocol is designed brilliantly is that it keeps toxicity to a very low level.

How might this technique evolve over the next 3 to 5 years?

Platforms like this at ACRO will be a way to publicize to a larger audience and community that this is available. They shouldn't be afraid to do it. It's an important service, and I expect it to hopefully pick up as one of the options. Again, patients and physicians are very frustrated. You're watching someone not only die from a horrible cancer because it's hard to treat, and patients generally would succumb to their disease, but they shouldn't do it in pain. If you have a service to offer them, it's quite amazing.

What makes this protocol so unique as well is that it doesn't treat the tumor per se; it treats the celiac plexus, or the nerve plexus itself, with radiation. The same way that radiation has now been found to be effective for treating VTAC [ventricular tachycardia], you're basically doing a neuroablation; the high dose of radiation in this context, you're treating that. You have an option of treating the tumor as well on the protocol. But the beauty of that was that it treats the nerves where the source of the pain is, and it also then allows you to spare the bowel from radiation exposure, because you aren't treating the tumor itself. That novelty is a game changer, because it's a very strange concept for radiation oncologists to think about: giving radiation to an off-target site, essentially, or a semi-off-target site in this particular context. That's what makes it so unique and different: that you're treating an actual nerve plexus. And it works.

Reference

Lawrence YR, Miszczyk M, Dawson LA, et al. Celiac plexus radiosurgery for pain management in advanced cancer: a multicentre, single-arm, phase 2 trial. Lancet Oncol. 2024;25(8):1070-1079. doi:10.1016/S1470-2045(24)00223-7