pancreatic%20cancer
PANCREATIC CANCER
Pancreatic cancer is malignancy arising from the pancreas.
It is the 13th most common cancer in the world, 10th most common in the United States, and 4th leading cause of cancer-related deaths in the United Stated and Europe.
Exocrine tumors account for 95% of malignant pancreatic disease.
It is more common in women.
The median age of occurrence is at 71 years old.

Supportive Therapy

Palliative Therapy
  • Ensures quality of life
  • Especially recommended for patients w/ unresectable & metastatic pancreatic cancer

Stent Placement

  • Endoscopically-placed stents are preferred for patients w/ biliary or duodenal obstruction
    • Metal stents are recommended for patients w/ life expectancy of >3 mth
    • For patients w/ poor prognosis, plastic stents are more viable, but has to be replaced every 6 mth to avoid stent occlusion & ascending cholangitis
      • Plastic stents are preferred in cases of biliary sepsis
    • Has less complications than percutaneous insertion
  • Has good short-term outcomes but may only last for >1 yr
  • Percutaneous transhepatic biliary drainage w/ stent placement may be done if endoscope-guided placement is not possible
    • Also recommended for patients w/ gastric outlet obstruction w/ poor performance status

Gastric Bypass

  • Performed to relieve biliary obstruction
  • Recommended for patients w/ unresectable pancreatic cancer during surgery & w/ good prognosis
  • Pros: Lower failure rates & better long-term outcomes
  • Cons: More expensive, delayed oral feeding, longer hospital stay, higher complication rate

Gastrojejunostomy Tubes

  • Recommended for pancreatic cancer patients w/ good performance status w/ gastric outlet obstruction
  • May be used for decompression and feeding support in patients w/ shorter life expectancies

Pain Relief

  • Pain in pancreatic cancer is most often associated w/ tumor size causing celiac plexus invasion & perineural infiltration
  • Opioids (eg Morphine) may be given for temporary relief from pain
  • Neurolytic celiac plexus block (NCPB) with ethyl alcohol has been used for pain control w/ 70-95% success rate
    • W/ low complication rate & long duration of effect (1-12 mth)
    • Highly recommended for patients intolerant of opiate analgesics
  • High intensity focused ultrasound treatment, intrathecal/epidural anesthesia are other options for control of moderate to severe pain in pancreatic cancer
  • Radiation therapy may help control abdominal pain caused by large tumors
    • May be given w/ or w/o chemotherapy
    • Studies show that 88% of patients achieved pain control w/ radiation therapy
    • Indicated for severe pain refractory to Morphine & other analgesics
    • Also helps decrease oral analgesic use

Low-Molecular-Weight Heparin (LMWH)

  • First-line treatment for pancreatic cancer patients w/ venous thromboembolic diseases (eg pulmonary embolism, deep venous thrombosis, thrombophlebitis migrans)
  • Warfarin may be given to patients w/ contraindications to LMWH

Pancreatic Enzyme Replacement

  • Oral pancreatic exocrine enzyme replacement therapy is recommended for pancreatic cancer patients w/ exocrine enzyme insufficiency or deficiency
    • This may be due to tumor-induced damage, pancreatic duct blockage, or secondary to surgical resection
  • Should be started immediately after pancreatic resection & in symptomatic unresectable pancreatic cancer patients

Recurrence Therapy

Recurrence After Resection

  • Confirmatory biopsy is recommended prior to treatment
  • Clinical trial is preferred

Local recurrence

  • Chemoradiation is suggested w/ biopsy-confirmed local recurrence if not previously given
  • Chemotherapy is preferred for patients previously given radiation therapy
  • For patients w/ poor performance status, supportive treatment is a preferred option

Metastatic disease w/ or w/o local recurrence

  • Treatment depends on interval after previous therapy
  • Supportive care is recommended if alternative chemotherapy & clinical trials are unsuccessful & if patient has a poor performance status
  • Recommended therapy for patients w/ completed therapy >6 mth prior to diagnosis of recurrence:
    • Previous therapeutic regimen
    • Second-line therapy
      • Gemcitabine-based regimen [eg GEMOX (Gemcitabine + Oxaliplatin), GTX] if previously given Fluoropyrimidine-based therapy
      • Fluoropyrimidine-based regimen (eg CapeOx, FOLFOX) if previously given Gemcitabine-based therapy
  • For patients w/ completed therapy <6 mth prior to diagnosis of recurrence:
    • Switching to recommended second-line therapy
      • Gemcitabine-based regimen if previously given Fluoropyrimidine-based therapy
      • Fluoropyrimidine-based regimen if previously given Gemcitabine-based therapy
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