Pancreatic cancer is the fifth leading cause of cancer death in the United States, with an overall 5-year survival rate of less than 5%. A minority of patients are candidates for surgical resection, but most treatment strategies focus on palliative care.
Methods
We discuss strategies in the diagnosis and treatment of resectable and locally advanced pancreatic cancer by reviewing available phase II and phase III trials, as well as large retrospective studies.
Results
Surgical resection for pancreatic cancer is done today with an operative mortality rate below 5% and a 5-year survival rate of approximately 25%. There is evidence that chemoradiation may improve survival and quality of life in both the adjuvant setting and for locally advanced disease. Operative, minimally invasive, and endoscopic techniques are successful in palliating pain and jaundice.
Conclusions
The diagnosis and treatment of pancreatic cancer continue to improve although most patients will succumb to their disease. Novel methods of earlier detection and more effective systemic therapies are needed to significantly improve outcomes.
References
1.
KelsenD.P., PortenoyR., ThalerH.. Pain as a predictor of outcome in patients with operable pancreatic carcinoma.Surgery.1997; 122: 53–59.
2.
EnayatiP.G., TraversoL.W., GalaganK.. The meaning of equivocal pancreatic cytology in patients thought to have pancreatic cancer.Am J Surg.1996; 171: 525–528.
3.
PovoskiS.P., KarpehMSJr, ConlonK.C.. Association of pre-operative biliary drainage with postoperative outcome following pan-creaticoduodenectomy.Ann Surg.1999; 230: 131–142.
4.
MagnusonT.H., BenderJ.S., DuncanM.D.. Utility of magnetic resonance cholangiography in the evaluation of biliary obstruction.J Am Coll Surg.1999; 189: 63–72.
5.
RittsR.E., PittH.A.. CA 19-9 in pancreatic cancer.Surg Oncol Clin N Am.1998; 7: 93–101.
6.
ElvinA., AnderssonT., ScheibenpflugL.. Biopsy of the pancreas with a biopsy gun.Radiology.1990; 176: 677–679.
7.
RiveraJ.A., Fernandez-del CastilloC., WarshawA.L.. The preoperative staging of pancreatic adenocarcinoma.Adv Surg.1996; 30: 97–122.
8.
MinnardE.A., ConlonK.C., HoosA.. Laparoscopic ultrasound enhances standard laparoscopy in the staging of pancreatic cancer.Ann Surg.1998; 228: 182–187.
9.
MakaryM.A., WarshawA.L., CentenoB.A.. Implications of peritoneal cytology for pancreatic cancer management.Arch Surg.1998; 133: 361–365.
10.
MerchantN.B., ConlonK.C., SaigoP.. Positive peritoneal cytology predicts unresectability of pancreatic adenocarcinoma.J Am Coll Surg.1999; 188: 421–426.
11.
HarrisonL.E., KlimstraD.S., BrennanM.F.. Isolated portal vein involvement in pancreatic adenocarcinoma: a contraindication for resection?Ann Surg.1996; 224: 342–349.
12.
FuhrmanG.M., LeachS.D., StaleyC.A.. Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group.Ann Surg.1996; 223: 154–162.
13.
HeslinM.J., HarrisonL.E., BrooksA.D.. Is intra-abdominal drainage necessary after pancreaticoduodenectomy?J Gastrointest Surg.1998; 2: 373–378.
14.
BrennanM.F., MocciaR.D., KlimstraD.. Management of adenocarcinoma of the body and tail of the pancreas.Ann Surg.1996; 223: 506–512.
15.
SchwarzR.E., HarrisonL.E., ConlonK.C.. The impact of splenectomy on outcomes after resection of pancreatic adenocarcinoma.J Am Coll Surg.1999; 188: 516–521.
16.
YeoC.J., CameronJ.L., LillemoeK.D.. Pancreaticoduodenectomy for cancer of the head of the pancreas: 201 patients.Ann Surg.1993; 221: 721–733.
17.
GeerR.J., BrennanM.F.. Prognostic indicators for survival after resection of pancreatic adenocarcinoma.Am J Surg.1993; 165: 68–73.
18.
SosaJ.A., BowmanH.M., GordonT.A.. Importance of hospital volume in the overall management of pancreatic cancer.Ann Surg.1998; 228: 429–438.
19.
LiebermanM.D., KilburnH., LindseyM.. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy.Ann Surg.1995; 222: 638–645.
20.
GlasgowR.E., MulvihillS.J.. Hospital volume influences outcome in patients undergoing pancreatic resection for cancer.West J Med.1996; 165: 294–300.
21.
KalserM.H., EllenbergS.S.. Pancreatic cancer: adjuvant combined radiation and chemotherapy following curative resection.Arch Surg.1985; 120: 899–903.
22.
Gastrointestinal Tumor Study Group.Further evidence of effective adjuvant combined radiation and chemotherapy following curative resection of pancreatic cancer.Cancer.1987; 59: 2006–2010.
23.
KlinkenbijlJ.H., JeekelJ., SahmoudT.. Adjuvant radiotherapy and 5-flourouracil after curative resection of cancer of the pancreas and periampullary region: phase III trial of the EORTC Gastrointestinal Tract Cancer Cooperative Group.Ann Surg.1999; 230: 776–784.
24.
WhittingtonR., BryerM.P., HallerD.G.. Adjuvant therapy of resected adenocarcinoma of the pancreas.Int J Radiat Oncol Biol Phys.1991; 21: 1137–1143.
25.
YeoC.J., AbramsR.A., GrochowL.B.. Pancreaticoduodenectomy for pancreatic adenocarcinoma: postoperative adjuvant chemoradiation improves survival. A prospective, single-institution experience.Ann Surg.1997; 225: 621–636.
26.
HoffmanJ.P., WeeseJ.L., SolinL.J.. A pilot study of preoperative chemoradiation for patients with localized adenocarcinoma of the pancreas.Am J Surg.1995; 169: 71–78.
27.
EvansD.B., RichT.A., ByrdD.R.. Preoperative chemoradiation and pancreaticoduodenectomy for adenocarcinoma of the pancreas.Arch Surg.1992; 127: 1335–1339.
28.
HoffmanJ.P., LipsitzS., PisanskyT.. Phase II trial of preoperative radiation therapy and chemotherapy for patients with localized, resectable adenocarcinoma of the pancreas: an Eastern Cooperative Oncology Group Study.J Clin Oncol.1998; 16: 317–323.
29.
PistersP.W., AbbruzzeseJ.L., JanjanN.A.. Rapid-fractionation preoperative chemoradiation, pancreaticoduodenectomy, and intraoperative radiation therapy for resectable pancreatic adenocarcinoma.J Clin Oncol.1998; 16: 3843–3850.
30.
LillemoeK.D., CameronJ.L., YeoC.J.. Pancreaticoduodenectomy: does it have a role in the palliation of pancreatic cancer?Ann Surg.1996; 223: 718–728.
31.
WatanapaP., WilliamsonR.C.. Surgical palliation for pancreatic cancer: developments during the past two decades.Br J Surg.1992; 79: 8–20.
32.
van den BoschR.P., van der SchellingG.P., KlinkenbijlJ.H.. Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas.Ann Surgery.1994; 219: 18–24.
33.
LillemoeK.D., CameronJ.L., HardacreJ.M.. Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial.Ann Surg.1999; 230: 322–330.
34.
LillemoeK.D., CameronJ.L., KaufmanH.S.. Chemical splanchnicectomy in patients with unresectable pancreatic cancer: a prospective randomized trial.Ann Surg.1993; 217: 447–457.
35.
MoertelC.G., FrytalsS., HahnR.G.. Therapy of locally unresectable pancreatic adenocarcinoma: a randomized comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-fluorouracil) and high dose radiation + 5-fluorouracil. The Gastrointestinal Tumor Study Group.Cancer.1981; 48: 1705–1710.
36.
KlaassenD.J., MacIntyreJ.M., CattonG.E.. Treatment of locally unresectable cancer of the stomach and pancreas: a randomized comparison of 5-fluorouracil alone with radiation plus concurrent and maintenance 5-fluorouracil. An Eastern Cooperative Oncology Group study.J Clin Oncol.1985; 3: 373–378.
37.
Gastrointestinal Tumor Study Group.Treatment of locally unresectable carcinoma of the pancreas: comparison of combined-modality therapy (chemotherapy plus radiotherapy) to chemotherapy alone.J Natl Cancer Inst.1988; 80: 751–755.
38.
MunzoneE., De BraudF., OrlandoL.. Combined modality treatment for locally advanced (LA) pancreatic carcinoma (PC): ECF (epirubicin, cisplatin, and fluorouracil as continuous infusion), plus concomitant three-dimensional conformal radiotherapy 3D-CRT.Proc Annu Meet Am Soc Clin Oncol.1999; A1125.
