pancreatic malignancy

UPDATES ON MANAGEMENT

OF PANCREATIC

MALIGNANCY

PANCREATIC MALIGNANCY

Malignancy near the bile duct

tend to cause obstructive jaundice

Pancreatic lesions in the body or tail

tend to be manifested as pain or a mass effect.

PANCREATIC MALIGNANCIES


RISK FACTORS

ESTABLISHEDTobacco

Inherited susceptibility

ASSOCIATED

Chronic pancreatitis

Type 2 Diabetes

Obesity

POSSIBLE

Physical activity

Certain pesticides

High carbohydrates


TUMOR MARKERS

Carbohydrate antigen 19-9 (CA 19-9) Elevated in upto 75% of the paitents with pancreatic

adenoca 50% of tumor


IMAGING STUDIES

RUQ ultrasound

CT

MRI

MRCP

ERCP

PTC

PET


NON-INVASIVE STAGING

GOLD STANDARD

Multidetector spiral CT (up to 64 slices) (MDRCT)

Identifies adjacent vascular structures, the superior mesenteric artery and celiac axis

90 % sensitivity and specificity for vascular study

Determines tissue planes and degree of circumferential involvement

Distant metastasis can be seen

Peritoneal dessimination , hepatic involvement and pulmonary involvement can be determined

MDRCT combined with Lap US yields better results


UNRESECTABLE TUMORS

Cases have increased due to:

Very good CT MDR in picking up the vascular disease

Picking up small volume liver disease

Picking up extra pancreatic disease

Peritoneal disease

Visible disease


ROLE OF ADJUVANT CHEMOTHERAPY IN PANCREATIC MALIGNANCY

5 year survival rate after resection is under 20%

80% of resectable tumors are systemic, hence adjuvant therapy is imperative

There were already 6 studies about adjuvant chemotherapy:


ADJUVANT THERAPY STUDY #1

Mortell in 1960

Surgery + 5 FU + chemoradiation using split course of 40 grey and chemo

Result: increased survival from 11 to 20 months



URTC pancreatic and periampullary site cancer

use split course of chemoradiotherapy

Results: 218 patients showed 20% increase in survival



Norway Study

Chemotherapy alone AMF regimen

Conclusion chemotherapy may postpone recurrence but does not improve the survival

rate



ASPACI trial European Study

289 patients Group I chemotherapy versus non chemo

Group II chemoradioation versus non chemo-radiation

256 patients Group I chemo vs observation

Group II chemoradiation vs observation

Conclusion: adjuvant chemoradiation good for resectable tumor

chemoradiation deleterious to non resectable tumor

ASPAC 1 chemotherapy is beneficial but can not answer the benefit of chemoradiation



KANKA 1 Germany Study

358 randomized patients

Adjuvant Gemcitabine versus observation

Results: showed established improvement in disease free interval

Conclusion:

chemotherapy beneficial after pancreatectomy

reaffirm ASPAC1 result which showed benefit of chemotherapy



RTOD 97-04 American Study

518 subjects

Gemcitarabine versus 5 FU

Results: Gemcitabine is superior than 5 FU with median survival of 20.6 months versus 17

months of 5 FU

NEOADJUVANT CHEMOTHERAPY

(DUKE UNIVERSITY)

Platform 5 FU based neoadjuvant chemotherapy

Advantages Multimodality conversion of large tumor to a resectable

tumor, thus avoiding morbidity of whipples procedure

Delivery of chemotherapy in a well oxygenated body works better

Potential to improve the resectability of borderline resectable tumor

Disadvantages: Missed opportunity for resection due to disease progression

Complication of chemotherapy

Questions of increase in post-op complication


GOALS FOR RESECTION

R0 zero resection with hitologically zero margin

R1 zero resection but with microscopically positive margin

R2 left some tumor behind


TWO PATHS IN THERAPY


All are required to have

staging CT scan (MDRCT)

Laparoscopy

Surgical Approach

Neoadjuvant

Approach

Chemoradiation 5-6 weeks

3-6 weeks restRestaging

Restaging

CT is not that reliable compared to pre-operative staging

Shrinkage is not a good sign of tumor containment

tumor shrinkage Explore Laparotomy

Increase in the size Confirmatory FNA Palliative Therapy

PANCREATIC MALIGNANCIESPANCREATIC MALIGNANCIES

NEOADJUVANT CHEMOTHERAPY

(DUKE UNIVERSITY)

NEOADJUVANT THERAPY RESEARCH

(DUKE UNIVERSITY)

Results:

Potentially resectable tumors 3 deaths from the complication of biliary

stent occlusion

20% metastatic disease at the time of restaging

60% get resected with: 72 % negative nodes

25 % negative margin

small percent are complete responders



(DUKE UNIVERSITY)

Potentially Locally Advanced Tumors

77% - defined morbidity and mortality chemoradiation

20% - become metastic disease

70-80% are resectable

70% have negative margin

No complete responders.


Conclusion

lesser mortality outcomes with neodjuvant therapy

Summary 50-60% underwent neoadjuvant therapy can be

resected

5 FU based Neoadjuvant chemotherapy over a 5-6 weeks course show 15-20 % locally advanced

tumor can be resected.



(DUKE UNIVERSITY)

The challenge to treat pancreatic cancer is still at

large.

pancreatic malignancy

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