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
ESTABLISHED

ASSOCIATED

POSSIBLE

Tobacco
Inherited susceptibility
Chronic pancreatitis
Type 2 Diabetes
Obesity
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 <2 cm will have a normal level
Level appear related to size and extent of the disease
Also elevated in cholestatic disease and other malignancies
Sensitive when it goes beyond thousand.

Carcinoembryonic antigen (CEA)

May be elevated with any of the periampullary
adenocarcinoma but more typically with bile duct
and duodenal adenoca

K ras mutation
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

PANCREATIC MALIGNANCIES

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

All are required to have
staging CT scan (MDRCT)
Laparoscopy
Neoadjuvant
Approach
Surgical Approach
Chemoradiation 5-6 weeks
Restaging

3-6 weeks rest

PANCREATIC MALIGNANCIES

NEOADJUVANT CHEMOTHERAPY
(DUKE UNIVERSITY)

Restaging
CT is not that reliable compared to preoperative staging

Shrinkage is not a good sign of tumor

containment
tumor shrinkage Explore Laparotomy
Increase in the size Confirmatory FNA
Palliative Therapy

PANCREATIC MALIGNANCIES

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

NEOADJUVANT THERAPY RESEARCH

(DUKE UNIVERSITY)

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

The challenge to
treat pancreatic
cancer is still at
large.