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gastroenterology
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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
PANCREATIC MALIGNANCIES
RISK FACTORS
ESTABLISHEDTobacco
Inherited susceptibility
ASSOCIATED
Chronic pancreatitis
Type 2 Diabetes
Obesity
POSSIBLE
Physical activity
Certain pesticides
High carbohydrates
PANCREATIC MALIGNANCIES
TUMOR MARKERS
Carbohydrate antigen 19-9 (CA 19-9) Elevated in upto 75% of the paitents with pancreatic
adenoca 50% of tumor
PANCREATIC MALIGNANCIES
IMAGING STUDIES
RUQ ultrasound
CT
MRI
MRCP
ERCP
PTC
PET
PANCREATIC MALIGNANCIES
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
PANCREATIC MALIGNANCIES
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
PANCREATIC MALIGNANCIES
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:
PANCREATIC MALIGNANCIES
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
PANCREATIC MALIGNANCIES
ADJUVANT THERAPY STUDY #2
URTC pancreatic and periampullary site cancer
use split course of chemoradiotherapy
Results: 218 patients showed 20% increase in survival
PANCREATIC MALIGNANCIES
ADJUVANT THERAPY STUDY #3
Norway Study
Chemotherapy alone AMF regimen
Conclusion chemotherapy may postpone recurrence but does not improve the survival
rate
PANCREATIC MALIGNANCIES
ADJUVANT THERAPY STUDY #4
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
PANCREATIC MALIGNANCIES
ADJUVANT THERAPY STUDY #5
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
PANCREATIC MALIGNANCIES
ADJUVANT THERAPY STUDY #6
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
PANCREATIC MALIGNANCIES
GOALS FOR RESECTION
R0 zero resection with hitologically zero margin
R1 zero resection but with microscopically positive margin
R2 left some tumor behind
PANCREATIC MALIGNANCIES
TWO PATHS IN THERAPY
PANCREATIC MALIGNANCIES
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
PANCREATIC MALIGNANCIES
NEOADJUVANT THERAPY RESEARCH
(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.
PANCREATIC MALIGNANCIES
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.
PANCREATIC MALIGNANCIES
NEOADJUVANT THERAPY RESEARCH
(DUKE UNIVERSITY)
The challenge to treat pancreatic cancer is still at
large.