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Pancreatic Cancer

- Analgesics - Stages I and II - Radical pancreatic resection plus chemotherapy - ESPAC-3 trial after resection: compared with 5-fluorouracil (5-FU) and folinic acid, gemcitabine did not improve overall survival. - Currently, postoperative gemcitabine alone or in combination with 5-FU " “based chemoradiation is the current standard of care; preoperative neoadjuvant treatment trials are in progress.

- Stage III - Standard: Chemotherapy with gemcitabine-based regimens; added chemoradiation is controversial. - FLOFIRINOX and gemcitabine " ”nab-paclitaxel were recently shown to have a benefit in patients with metastatic disease; may be tried in patients with locally advanced disease - Palliation of biliary obstruction by endoscopic, surgical, or radiologic methods - Intraoperative radiation therapy and/or implantation of radioactive substances

- Standard treatment options - Pancreaticoduodenectomy, Whipple procedure, en bloc resection of the head of the pancreas, distal common bile duct, duodenum, jejunum, and gastric antrum - Total pancreatectomy - Distal pancreatectomy for body and tail tumors

- Nonstandard surgeries - Pylorus-preserving pancreaticoduodenectomy, regional pancreatectomy - Palliative bypass - Biliary decompression; gastrojejunostomy for gastric outlet obstruction; duodenal endoprosthesis for obstruction

para>Chronic pancreatitis can present with similar pain, weight loss, jaundice, and an inflammatory mass on imaging. ‚

TREATMENT

  • Surgical resection: only chance of cure; no role for pancreatic resection in metastatic disease. As few as 15 " “20% are candidates for resection.
  • Criteria for unresectability: extrapancreatic spread, encasement or occlusion of major vessels, distant metastases
  • New combination chemotherapy regimens may offer advantages over gemcitabine. Standard therapies remain unsatisfactory; thus, patients should be considered for clinical trials (3).

MEDICATION

  • Analgesics
  • Stages I and IIRadical pancreatic resection plus chemotherapyESPAC-3 trial after resection: compared with 5-fluorouracil (5-FU) and folinic acid, gemcitabine did not improve overall survival.Currently, postoperative gemcitabine alone or in combination with 5-FU " “based chemoradiation is the current standard of care; preoperative neoadjuvant treatment trials are in progress.
  • Stage IIIStandard: Chemotherapy with gemcitabine-based regimens; added chemoradiation is controversial.FLOFIRINOX and gemcitabine " ”nab-paclitaxel were recently shown to have a benefit in patients with metastatic disease; may be tried in patients with locally advanced diseasePalliation of biliary obstruction by endoscopic, surgical, or radiologic methodsIntraoperative radiation therapy and/or implantation of radioactive substances
  • Stage IVChemotherapy: Gemcitabine with erlotinib, or paclitaxel, or a fluoropyrimidine may modestly prolong survival compared with gemcitabine alone.Pain-relieving procedures (celiac or intrapleural block); supportive care; palliative decompression

ADDITIONAL THERAPIES

  • For resected tumors: postoperative radiation therapy with other chemotherapeutic agents
  • Intraoperative radiation therapy and/or implantation of radioactive substances (ongoing trials)
  • Biliary decompression with endoprosthesis or transhepatic drainage for bile duct obstruction
  • Celiac axis and intrapleural nerve blocks can provide effective pain relief for some patients.
  • Opiates may be needed for pain control.

SURGERY/OTHER PROCEDURES

  • Standard treatment optionsPancreaticoduodenectomy, Whipple procedure, en bloc resection of the head of the pancreas, distal common bile duct, duodenum, jejunum, and gastric antrumTotal pancreatectomyDistal pancreatectomy for body and tail tumors
  • Nonstandard surgeriesPylorus-preserving pancreaticoduodenectomy, regional pancreatectomyPalliative bypassBiliary decompression; gastrojejunostomy for gastric outlet obstruction; duodenal endoprosthesis for obstruction

ONGOING CARE

DIET

  • Anorexia, asthenia, pain, and depression may contribute to cachexia.
  • Fat malabsorption due to exocrine pancreatic insufficiency may contribute to malnutrition; pancreatic enzyme replacement may help to alleviate symptoms.
  • Fat-soluble vitamin deficiency may require replacement therapy.

PROGNOSIS

  • 90% diagnosed with pancreatic cancer die from the disease, predominantly from metastatic disease (3).
  • 5-year survival: ~30% if node-negative; 10% if node-positive. Median survival: 10 to 20 months
  • Metastatic cancer: 1 " “2% 5-year survival
  • For localized disease and small cancers (<2 cm) with no lymph node involvement and no extension beyond the capsule, complete surgical resection can yield a 5-year survival of 18 " “24%.
  • Detection of curable precursor lesions is a focus of current efforts to improve diagnosis and prognosis.

COMPLICATIONS

  • Diabetes mellitus, malabsorption, thrombophlebitis
  • Duodenal or distal bile duct obstruction
  • Surgical complications: intra-abdominal abscess, postgastrectomy syndromes, pancreaticojejunostomy, gastric and biliary anastomotic leaks; operative mortality varies.

REFERENCES

11 Chari ‚ ST, Kelly ‚ K, Hollingsworth ‚ MA, et al. Early detection of sporadic pancreatic cancer: summative review. Pancreas. 2015;44(5):693 " “712.22 Yadav ‚ D, Lowenfels ‚ AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology. 2013;144(6):1252 " “1261.33 Ryan ‚ DR, Hong ‚ TS, Bardeesy ‚ N. Pancreatic adenocarcinoma. N Engl J Med. 2014;371(11):1039 " “1049.44 De La Cruz ‚ MS, Young ‚ AP, Ruffin ‚ MT. Diagnosis and management of pancreatic cancer. Am Fam Physician. 2014;89(8):626 " “632.

CODES

ICD10

  • C25.9 Malignant neoplasm of pancreas, unspecified
  • C25.0 Malignant neoplasm of head of pancreas
  • C25.1 Malignant neoplasm of body of pancreas
  • C25.2 Malignant neoplasm of tail of pancreas
  • C25.7 Malignant neoplasm of other parts of pancreas
  • C25.8 Malignant neoplasm of overlapping sites of pancreas
  • C25.4 Malignant neoplasm of endocrine pancreas
  • C25.3 Malignant neoplasm of pancreatic duct

ICD9

  • 157.9 Malignant neoplasm of pancreas, part unspecified
  • 157.0 Malignant neoplasm of head of pancreas
  • 157.1 Malignant neoplasm of body of pancreas
  • 157.2 Malignant neoplasm of tail of pancreas
  • 157.8 Malignant neoplasm of other specified sites of pancreas
  • 157.4 Malignant neoplasm of islets of langerhans
  • 157.3 Malignant neoplasm of pancreatic duct

SNOMED

  • 372003004 Primary malignant neoplasm of pancreas
  • 372119009 Primary malignant neoplasm of head of pancreas
  • 93715005 Primary malignant neoplasm of body of pancreas
  • 94082003 Primary malignant neoplasm of tail of pancreas
  • 700423003 Adenocarcinoma of pancreas (disorder)
  • 93939009 Primary malignant neoplasm of pancreatic duct
  • 372142002 Carcinoma of pancreas (disorder)
  • 254612002 Carcinoma of endocrine pancreas (disorder)
  • 363369002 Carcinoma of tail of pancreas (disorder)
  • 93843007 Primary malignant neoplasm of islets of Langerhans
  • 363368005 Carcinoma of body of pancreas (disorder)
  • 326072005 Carcinoma of head of pancreas (disorder)
  • 254609000 Carcinoma of ampulla of Vater (disorder)

CLINICAL PEARLS

  • Sudden onset of diabetes mellitus in nonobese adults aged >40 years may warrant consideration of pancreatic cancer in selected cases.
  • Cancer of the exocrine pancreas is rarely curable; overall 5-year survival rate of <4%. Fewer than 20% of cases are localized at diagnosis.
  • Be wary of chronic pancreatitis, which can present with similar pain pattern, weight loss, jaundice, and an inflammatory mass on imaging.
  • Because of the dismal prognosis on standard therapy, all patients with pancreatic cancer should be considered for appropriate clinical trials