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New Treatments for Pancreatic Cancer

Pancreatic cancer is the second most common GI cancer in the U.S. Almost 30,000 cases a year pancreas cancer, pancreatic cancer. Virtually 100% fatal. Primarily a disease of the developed countries. Here are the statistics; down at the bottom worldwide, but itís number two in the U.S. and because of rounding to two decimal places, the incidence rate and the death rate are the same. This is virtually the same geographical distribution as for colorectal cancer. Risk factors in pancreatic cancer: cigarette smoking is important.

Chronic pancreatitis, acquired or the usual pancreatitis that you see in the alcoholic is a minor risk factor. It is a risk factor, it has been shown to be, but familial relapsing pancreatitis, hereditary pancreatitis is a major risk factor.

Genetics: K-ras activation is almost universal in pancreatic cancer. Interesting work has been done looking for K-ras mutations in the pancreatic juice by ERCP. There was a French study not too long ago in which they screened patients who had pancreatic disease, suspected of pancreatic cancer, and in every case except two in which they detected K-ras mutations.

Basically pancreatic cancer is mostly exocrine, and thatís all Iím going to talk about. Of the exocrines, the vast majority are adenocarcinoma, mainly ductal. And the significance of the ductal is the great degree of desmoplasia you see in these. The neuroendocrine carcinomas are important to distinguish because they behave differently. They are sensitive to different drugs, they are more indolent, more responsive.

This is a pancreatic cancer. You see these nests of very terrible looking, poorly differentiated cells. But itís immersed in this huge sea of scar tissue, desmoplasia.

Presenting symptoms: early symptoms are non-specific. Weight loss, anorexia, abdominal discomfort or pain. Jaundice can be an early or late presentation. A small subset of these patients with carcinomas of the head of the pancreas, the tumor will be located so that even at a small size it obstructs the common bile duct, and these are patients.

Staging: T1 and T2, which are resectable in anybodyís book, are tumors limited to the pancreas. Limited extension to the duodenum or to the ductus, T3, thatís still resectable in many hands. T4, to the stomach, spleen, colon, or the one that usually bars resection is the great vessels, which are the closest. And there is just zero or 1 depending on whether the regional nodes.

Surgery for pancreatic cancer is the radical pancreatoduodenectomy, the Whipple procedure. You take out a lot of tissue. Here itís all listed for you. Less than 25% of presenting pancreatic cancers will be resectable by the usual standards; which means, major vessel involvement bars resection. Historically the operative mortality of this procedure was very high.

Non-surgical decompression for the jaundice: there are two ways to do it. One is to insert a stent by ERCP. These are generally maintained longer, less subject to infection, but it is highly skill-dependent.

Radiotherapy is an effective modality for pain control in pancreatic cancer. Radiotherapy is the modality that is usually used for locally unresectability of the great vessels, is the most common reason, but still not metastasized distantly. It can even be used for pain control in someone with metastatic disease. Usually a patient with metastatic disease doesnít have too much time to wait for their relief. Thereís a small survival advantage for radiotherapy.