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 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
- Stage IV
- Chemotherapy: 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 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
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