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Pancreatic cancer

Table of Contents

GENERAL INFORMATION
CELLULAR CLASSIFICATION
STAGE INFORMATION
TNM definitions
AJCC stage groupings
Stage 0
Stage I
Stage II
Stage III
Stage IVA
Stage IVB
TREATMENT OPTION OVERVIEW
STAGE I PANCREATIC CANCER
STAGE II PANCREATIC CANCER
STAGE III PANCREATIC CANCER
STAGE IVA PANCREATIC CANCER
STAGE IVB PANCREATIC CANCER
RECURRENT PANCREATIC CANCER

GENERAL INFORMATION

Cancer of the exocrine pancreas is rarely curable. The highest cure rate occurs if the tumor is truly localized to the pancreas. Unfortunately, this stage of disease accounts for fewer than 20% of cases and results in approximately a 20% 5-year survival rate in patients with completely resected tumors, but only a 4% 5-year survival rate for all patients with pancreatic cancer. For patients with small cancers (less than 2 centimeters) with no lymph node metastases and no extension beyond the "capsule" of the pancreas, the survival rate following resection of the head of the pancreas approaches 20%. Improvements in imaging technology, including spiral computed tomographic scans, magnetic resonance imaging scans, positron emission tomographic scans, endoscopic ultrasound examination, and laparoscopic staging can aid in the diagnosis and the identification of patients with disease that is not amenable to resection.[1] For patients with advanced cancers, the overall survival rate of all stages is less than 1% at 5 years with most patients dying within 1 year.[2-5] Patients with any stage of pancreatic cancer can appropriately be considered candidates for clinical trials because of the poor response to chemotherapy, radiation therapy, and surgery as conventionally used. However, palliation of symptoms may be achieved with conventional treatment. Symptoms due to pancreatic cancer may depend on the site of the tumor within the pancreas and the degree of involvement. Palliative surgical or radiologic biliary decompression, relief of gastric outlet obstruction, and pain control may improve the quality of survival while not affecting overall survival. Palliative efforts may also be directed to the potentially disabling psychological events associated with the diagnosis and treatment of pancreatic cancer.[6]

References:

  1. Riker A, Libutti SK, Bartlett DL: Advances in the early detection, diagnosis, and staging of pancreatic cancer. Surgical Oncology 6(3): 157-169, 1998.

  2. Lillemoe KD: Current management of pancreatic carcinoma. Annals of Surgery 221(2): 133-148, 1995.

  3. Warshaw AL, Fernandez-del Castillo C: Pancreatic carcinoma. New England Journal of Medicine 326(7): 455-465, 1992.

  4. Nitecki SS, Sarr MG, Colby TV, et al.: Long-term survival after resection for ductal adenocarcinoma of the pancreas: is it really improving? Annals of Surgery 221(1): 59-66, 1995.

  5. Conlon KC, Klimstra DS, Brennan MF: Long-term survival after curative resection for pancreatic ductal adenocarcinoma: clinicopathologic analysis of 5-year survivors. Annals of Surgery 223(3), 273-279, 1996.

  6. Passik SD, Breitbart WS: Depression in patients with pancreatic carcinoma: diagnostic and treatment issues. Cancer 78(3): 615-626, 1996.

CELLULAR CLASSIFICATION

Malignant
duct cell carcinoma (90% of all cases)
acinar cell carcinoma
papillary mucinous carcinoma
signet ring carcinoma
adenosquamous carcinoma
undifferentiated carcinoma
mucinous carcinoma
giant cell carcinoma
mixed type (ductal-endocrine or acinar-endocrine)
small cell carcinoma
cystadenocarcinoma (serous and mucinous types)
unclassified
pancreatoblastoma
papillary-cystic neoplasm (this tumor has lower malignant potential, and
may be cured with surgery alone)[1,2]

Borderline
mucinous cystic tumor with dysplasia
intraductal papillary mucinous tumor with dysplasia
pseudopapillary solid tumor

References:

  1. Sanchez JA, Newman KD, Eichelberger MR, et al.: The papillary-cystic neoplasm of the pancreas. Archives of Surgery 125(11): 1502-1505, 1990.

  2. Warshaw AL, Compton CC, Lewandrowski K, et al.: Cystic tumors of the pancreas: new clinical, radiologic, and pathologic observations in 67 patients. Annals of Surgery 212(4): 432-443, 1990.

STAGE INFORMATION

The staging system for pancreatic exocrine cancer continues to evolve. The importance of staging beyond that of "resectable" and "unresectable" is uncertain since state-of-the-art treatment has demonstrated little impact on survival. However, in order to communicate a uniform definition of disease, knowledge of the extent of the disease is necessary. Cancers of the pancreas are commonly identified by the site of involvement within the pancreas. Surgical approaches differ for masses in the head, body, tail, or uncinate process of the pancreas.

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification.[1]

TNM definitions

Primary tumor (T)

TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: In situ carcinoma
T1: Tumor limited to the pancreas 2 cm or less in greatest dimension
T2: Tumor limited to the pancreas more than 2 cm in greatest dimension
T3: Tumor extends directly into any of the following: duodenum, bile duct,
or peripancreatic tissues
T4: Tumor extends directly into any of the following: stomach, spleen,
colon, or adjacent large vessels

Regional lymph nodes (N)
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph node metastasis

Distant metastasis (M)
MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis

AJCC stage groupings

Stage 0

Tis, N0, M0

Stage I

T1, N0, M0
T2, N0, M0

Stage II

T3, N0, M0

Stage III

T1, N1, M0
T2, N1, M0
T3, N1, M0

Stage IVA

T4, Any N, M0

Stage IVB

Any T, Any N, M1

References:

  1. Exocrine pancreas. In: American Joint Committee on Cancer: AJCC Cancer Staging Manual. Philadelphia, Pa: Lippincott-Raven Publishers, 5th ed., 1997, pp 121-126.

TREATMENT OPTION OVERVIEW

The survival rate of patients with any stage of pancreatic exocrine cancer is poor. Clinical trials are appropriate alternatives for treatment of patients with any stage of disease and should be considered prior to selecting palliative approaches. To provide optimal palliation, determination of resectability must be made. Standard staging studies for resectability include computed tomographic scan, visceral angiography or magnetic resonance imaging scan, laparotomy, and laparoscopy. The introduction of minimally invasive techniques, such as laparoscopy and laparoscopic ultrasound, may decrease the need for laparotomy.[1,2] Surgical resection remains the primary modality when feasible since, on occasion, resection can lead to long-term survival and provides effective palliation.[3,4] Frequently, malabsorption due to exocrine insufficiency contributes to malnutrition. Attention to pancreatic enzyme replacement can help alleviate this problem. For additional information, refer to the PDQ supportive care summary on nutrition. Celiac axis (and intrapleural) nerve blocks can provide highly effective and long-lasting control of pain for some patients.

The designations in PDQ that treatments are "standard" or "under clinical evaluation" are not to be used as a basis for reimbursement determinations.

References:

  1. John TG, Greig JD, Carter DC, et al.: Carcinoma of the pancreatic head and periampullary region: tumor staging with laparoscopy and laparoscopic ultrasonography. Annals of Surgery 221(2): 156-164, 1995.

  2. Minnard EA, Conlon KC, Hoos A, et al.: Laparoscopic ultrasound enhances standard laparoscopy in the staging of pancreatic cancer. Annals of Surgery 228(2): 182-187, 1998.

  3. Yeo CJ, Cameron JL, Lillemoe KD, et al.: Pancreaticoduodenectomy for cancer of the head of the pancreas: 201 patients. Annals of Surgery 221(6): 721-733, 1995.

  4. Conlon KC, Klimstra DS, Brennan MF: Long-term survival after curative resection for pancreatic ductal adenocarcinoma: clinicopathologic analysis of 5-year survivors. Annals of Surgery 223(3), 273-279, 1996.

STAGE I PANCREATIC CANCER

Only 20% of the patients receiving surgery will be eligible for total resection. The operative mortality rate for a radical pancreatic resection is less than 10%.[1,2] For suitable patients post-pancreatectomy, fluorouracil plus regional radiation appears to offer a survival advantage. Approximately 40% of such patients whose tumors are confined to the head of the pancreas may be alive at two years, particularly those with T1, N0 tumors.[3-6]

Treatment options:

Standard:

Radical pancreatic resection:
Whipple procedure (pancreaticoduodenal resection) with or without
resection of the superior mesenteric vein
Total pancreatectomy when necessary for adequate margins
Distal pancreatectomy for tumors of the body and tail of the
pancreas [7,8]
Radical pancreatic resection plus postoperative chemotherapy and
irradiation [3,4]

Under clinical evaluation:
Radiation therapy with and without chemotherapy is being tested as
preoperative, intraoperative, and/or postoperative adjuvant therapy for
resected patients.[3,4,9]

References:

  1. Edge SB, Schmieg RE, Rosenlof LK, et al.: Pancreas cancer resection outcome in American university centers in 1989-1990. Cancer 71(11): 3502-3508, 1993.

  2. Cameron JL, Pitt HA, Yeo CJ, et al.: One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Annals of Surgery 217(5): 430-438, 1993.

  3. Gastrointestinal Tumor Study Group: Further evidence of effective adjuvant combined radiation and chemotherapy following curative resection of pancreatic cancer. Cancer 59(12): 2006-2010, 1987.

  4. Gastrointestinal Tumor Study Group: Pancreatic cancer: adjuvant combined radiation and chemotherapy following curative resection. Archives of Surgery 120(8): 899-903, 1985.

  5. Cameron JL, Crist DW, Sitzmann JV, et al.: Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer. American Journal of Surgery 161(1): 120-125, 1991.

  6. Yeo CJ, Cameron JL, Lillemoe KD, et al.: Pancreaticoduodenectomy for cancer of the head of the pancreas: 201 patients. Annals of Surgery 221(6): 721-733, 1995.

  7. Dalton RR, Sarr MG, van Heerden JA, et al.: Carcinoma of the body and tail of the pancreas: is curative resection justified? Surgery 111(5): 489-494, 1992.

  8. Brennan MF, Moccia RD, Klimstra D: Management of adenocarcinoma of the body and tail of the pancreas. Annals of Surgery 223(5): 506-512, 1996.

  9. Tepper JE, Noyes D, Krall JM, et al.: Intraoperative radiation therapy of pancreatic carcinoma: a report of RTOG-8505. International Journal of Radiation Oncology, Biology, Physics 21(5): 1145-1149, 1991.

STAGE II PANCREATIC CANCER

Stage II pancreatic cancer includes virtually all tumors of the uncinate process. A few patients with stage II pancreatic cancer are technically resectable, but cures have only rarely been reported. Postoperative irradiation plus fluorouracil in resected patients has also been studied.[1,2] More frequently, palliative bypass of biliary obstruction by surgical, endoscopic, or radiologic means should be performed.

While there are some data demonstrating a survival advantage associated with combined chemotherapy and radiation therapy,[3] most patients with unresectable pancreatic cancer should be considered for participation in clinical trials. Radiation therapy alone may palliate symptoms, but survival benefit is not usually demonstrable.

Pain associated with unresectable pancreatic cancer may be palliated with radiation therapy, with or without chemotherapy,[1,3-5] or with chemical splanchnicectomy with 50% alcohol at the time of surgical exploration.[6] Celiac nerve blocks and local neurosurgical procedures to relieve pain can be considered.[7]

Treatment options:

Standard:

1. Pancreatectomy when feasible, with or without adjuvant chemotherapy and radiation therapy.[2,6]

2. Radiation therapy with or without chemotherapy.[3-5,8]

3. Palliative surgical biliary bypass, percutaneous radiologic biliary stent placement, or endoscopic biliary stent placement.[6]

Under clinical evaluation:
1. Preoperative irradiation plus chemotherapy.

2. Radiation therapy with radiosensitizers.

3. Chemotherapy clinical trials.

4. Intraoperative radiation therapy and/or implantation of radioactive sources.[1]

References:

  1. Tepper JE, Noyes D, Krall JM, et al.: Intraoperative radiation therapy of pancreatic carcinoma: a report of RTOG-8505. International Journal of Radiation Oncology, Biology, Physics 21(5): 1145-1149, 1991.

  2. Gastrointestinal Tumor Study Group: Pancreatic cancer: adjuvant combined radiation and chemotherapy following curative resection. Archives of Surgery 120(8): 899-903, 1985.

  3. Moertel CG, Frytak S, Hahn RG, et al.: Therapy of locally unresectable pancreatic carcinoma: a randomized comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-fluorouracil), and high dose radiation + 5-fluorouracil. Cancer 48(8): 1705-1710, 1981.

  4. Whittington R, Solin L, Mohiuddin M, et al.: Multimodality therapy of localized unresectable pancreatic adenocarcinoma. Cancer 54(9): 1991-1998, 1984.

  5. Moertel CG, Childs DS, Reitemeier RJ, et al.: Combined 5-fluorouracil and supervoltage radiation therapy of locally unresectable gastrointestinal cancer. Lancet 2(7626): 865-867, 1969.

  6. van den Bosch RP, van der Schelling GP, Klinkenbijl JH, et al.: Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas. Annals of Surgery 219(1): 18-24, 1994.

  7. Polati E, Finco G, Gottin L, et al.: Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer. British Journal of Surgery 85(2): 199-201, 1998.

  8. Whittington R, Bryer MP, Haller DG, et al.: Adjuvant therapy of resected adenocarcinoma of the pancreas. International Journal of Radiation Oncology, Biology, Physics 21(5): 1137-1143, 1991.

STAGE III PANCREATIC CANCER

A few patients with stage III pancreatic cancer are technically resectable, but a cure has rarely been reported. More frequently, palliative bypass of biliary obstruction by surgical, endoscopic, or radiologic means should be performed.

While there are data demonstrating a survival advantage associated with combined chemotherapy and radiation therapy,[1] most patients with unresectable pancreatic cancer should be considered for participation in clinical trials. Radiation therapy alone may palliate symptoms, but survival benefit is not demonstrable.

Pain associated with unresectable pancreatic cancer may be palliated with radiation therapy, with or without chemotherapy,[1-4] or with chemical splanchnicectomy with 50% alcohol at the time of surgical exploration.[5] Celiac nerve blocks and local neurosurgical procedures to relieve pain can be considered.[6]

Treatment options:

Standard:

1. Pancreatectomy when feasible, with or without adjuvant chemotherapy and radiation therapy.[5,7]

2. Radiation therapy with or without chemotherapy.[1-3,8]

3. Palliative surgical biliary and/or gastric bypass, percutaneous radiologic biliary stent placement, or endoscopic biliary stent placement.[7]

Under clinical evaluation:
1. Neoadjuvant radiation and chemotherapy.[9,10]

2. Radiation therapy with radiosensitizers.

3. Chemotherapy clinical trials.

4. Intraoperative radiation therapy and/or implantation of radioactive sources.[4]

References:

  1. Moertel CG, Frytak S, Hahn RG, et al.: Therapy of locally unresectable pancreatic carcinoma: a randomized comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-fluorouracil), and high dose radiation + 5-fluorouracil. Cancer 48(8): 1705-1710, 1981.

  2. Whittington R, Solin L, Mohiuddin M, et al.: Multimodality therapy of localized unresectable pancreatic adenocarcinoma. Cancer 54(9): 1991-1998, 1984.

  3. Moertel CG, Childs DS, Reitemeier RJ, et al.: Combined 5-fluorouracil and supervoltage radiation therapy of locally unresectable gastrointestinal cancer. Lancet 2(7626): 865-867, 1969.

  4. Tepper JE, Noyes D, Krall JM, et al.: Intraoperative radiation therapy of pancreatic carcinoma: a report of RTOG-8505. International Journal of Radiation Oncology, Biology, Physics 21(5): 1145-1149, 1991.

  5. Gastrointestinal Tumor Study Group: Pancreatic cancer: adjuvant combined radiation and chemotherapy following curative resection. Archives of Surgery 120(8): 899-903, 1985.

  6. Polati E, Finco G, Gottin L, et al.: Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer. British Journal of Surgery 85(2): 199-201, 1998.

  7. van den Bosch RP, van der Schelling GP, Klinkenbijl JH, et al.: Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas. Annals of Surgery 219(1): 18-24, 1994.

  8. Whittington R, Bryer MP, Haller DG, et al.: Adjuvant therapy of resected adenocarcinoma of the pancreas. International Journal of Radiation Oncology, Biology, Physics 21(5): 1137-1143, 1991.

  9. Hoffman JP, Lipsitz S, Pisansky T, et al.: Phase II trial of preoperative radiation therapy and chemotherapy for patients with localized, resectable adenocarcinoma of the pancreas: an Eastern Cooperative Oncology Group Study. Journal of Clinical Oncology 16(1): 317-323, 1998.

  10. Spitz FR, Abbruzzese JL, Lee JE, et al.: Preoperative and postoperative chemoradiation strategies in patients treated with pancreaticoduodenectomy for adenocarcinoma of the pancreas. Journal of Clinical Oncology 15(3): 928-937, 1997.

STAGE IVA PANCREATIC CANCER

A few patients with stage IVA pancreatic cancer are technically resectable, but a cure has rarely been reported. More frequently, palliative bypass of biliary obstruction by surgical, endoscopic, or radiologic means should be performed.

While there are data demonstrating a survival advantage associated with combined chemotherapy and radiation therapy,[1] most patients with unresectable pancreatic cancer should be considered for participation in clinical trials. Radiation therapy alone may palliate symptoms, but survival benefit is not demonstrable.

Pain associated with unresectable pancreatic cancer may be palliated with radiation therapy, with or without chemotherapy,[1-4] or with chemical splanchnicectomy with 50% alcohol at the time of surgical exploration.[5] Celiac nerve blocks and local neurosurgical procedures to relieve pain can be considered.[6]

Treatment options:

Standard:

1. Pancreatectomy when feasible, with or without adjuvant chemotherapy and radiation therapy.[5,7]

2. Radiation therapy with or without chemotherapy.[1-3,8]

3. Palliative surgical biliary and/or gastric bypass, percutaneous radiologic biliary stent placement, or endoscopic biliary stent placement.[7]

Under clinical evaluation:
1. Neoadjuvant radiation and chemotherapy.[9,10]

2. Radiation therapy with radiosensitizers.

3. Chemotherapy clinical trials.

4. Intraoperative radiation therapy and/or implantation of radioactive sources.[4]

References:

  1. Moertel CG, Frytak S, Hahn RG, et al.: Therapy of locally unresectable pancreatic carcinoma: a randomized comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-fluorouracil), and high dose radiation + 5-fluorouracil. Cancer 48(8): 1705-1710, 1981.

  2. Whittington R, Solin L, Mohiuddin M, et al.: Multimodality therapy of localized unresectable pancreatic adenocarcinoma. Cancer 54(9): 1991-1998, 1984.

  3. Moertel CG, Childs DS, Reitemeier RJ, et al.: Combined 5-fluorouracil and supervoltage radiation therapy of locally unresectable gastrointestinal cancer. Lancet 2(7626): 865-867, 1969.

  4. Tepper JE, Noyes D, Krall JM, et al.: Intraoperative radiation therapy of pancreatic carcinoma: a report of RTOG-8505. International Journal of Radiation Oncology, Biology, Physics 21(5): 1145-1149, 1991.

  5. Gastrointestinal Tumor Study Group: Pancreatic cancer: adjuvant combined radiation and chemotherapy following curative resection. Archives of Surgery 120(8): 899-903, 1985.

  6. Polati E, Finco G, Gottin L, et al.: Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer. British Journal of Surgery 85(2): 199-201, 1998.

  7. van den Bosch RP, van der Schelling GP, Klinkenbijl JH, et al.: Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas. Annals of Surgery 219(1): 18-24, 1994.

  8. Whittington R, Bryer MP, Haller DG, et al.: Adjuvant therapy of resected adenocarcinoma of the pancreas. International Journal of Radiation Oncology, Biology, Physics 21(5): 1137-1143, 1991.

  9. Hoffman JP, Lipsitz S, Pisansky T, et al.: Phase II trial of preoperative radiation therapy and chemotherapy for patients with localized, resectable adenocarcinoma of the pancreas: an Eastern Cooperative Oncology Group Study. Journal of Clinical Oncology 16(1): 317-323, 1998.

  10. Spitz FR, Abbruzzese JL, Lee JE, et al.: Preoperative and postoperative chemoradiation strategies in patients treated with pancreaticoduodenectomy for adenocarcinoma of the pancreas. Journal of Clinical Oncology 15(3): 928-937, 1997.

STAGE IVB PANCREATIC CANCER

The low objective response rate and lack of survival benefit with current chemotherapy indicates clinical trials as appropriate treatment of all newly diagnosed patients. Occasional patients have palliation of symptoms when treated by chemotherapy with well-tested older drugs. A randomized, placebo- controlled trial demonstrated that chemical splanchnicectomy with 50% alcohol at the time of surgical exploration significantly reduces pain, particularly in those patients with preoperative pain.[1] Gemcitabine has demonstrated activity in pancreatic cancer and is a useful palliative agent.[2,3]

Treatment options:

Standard:

1. Chemotherapy with gemcitabine or fluorouracil.[2,3]

2. Pain relieving procedures (e.g., celiac or intrapleural block) and supportive care.[4]

3. Palliative surgical biliary bypass, percutaneous radiologic biliary stent placement, or endoscopically placed biliary stents.[5]

Under clinical evaluation:
Clinical trials evaluating modulated fluorouracil, new anticancer agents, or
biologicals (phase I and II).[2,6-12]

References:

  1. Chaitchik S, Borovik R, Robinson E, et al.: Adjuvant chemotherapy for stage II breast cancer: CMF vs alternating CMF-VA: a national randomized trial. Proceedings of the American Society of Clinical Oncology 8: A-186, 48, 1989.

  2. Rothenberg ML, Moore MJ, Cripps MC, et al.: A phase II trial of gemcitabine in patients with 5-FU-refractory pancreas cancer. Annals of Oncology 7(4): 347-353, 1996.

  3. Burris HA, Moore MJ, Andersen J, et al.: Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial. Journal of Clinical Oncology 15(6): 2403-2413, 1997.

  4. Polati E, Finco G, Gottin L, et al.: Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer. British Journal of Surgery 85(2): 199-201, 1998.

  5. van den Bosch RP, van der Schelling GP, Klinkenbijl JH, et al.: Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas. Annals of Surgery 219(1): 18-24, 1994.

  6. Macdonald JS, Widerlite L, Schein PS: Biology, diagnosis, and chemotherapeutic management of pancreatic malignancy. Advances in Pharmacology and Chemotherapy 14: 107-142, 1977.

  7. Bukowski RM, Balcerzak SP, O'Bryan RM, et al.: Randomized trial of 5-fluorouracil and mitomycin-C with or without streptozotocin for advanced pancreatic cancer. Cancer 52(9): 1577-1582, 1983.

  8. DeCaprio JA, Mayer RJ, Gonin R, et al.: Fluorouracil and high-dose leucovorin in previously untreated patients with advanced adenocarcinoma of the pancreas: results of a phase II trial. Journal of Clinical Oncology 9(12): 2128-2133, 1991.

  9. Kelsen D, Hudis C, Niedzwiecki D, et al.: A phase III comparison trial of streptozotocin, mitomycin, and 5-fluorouracil with cisplatin, cytosine arabinoside, and caffeine in patients with advanced pancreatic carcinoma. Cancer 68(5): 965-969, 1991.

  10. O'Connell MJ: Current status of chemotherapy for advanced pancreatic and gastric cancer. Journal of Clinical Oncology 3(7): 1032-1039, 1985.

  11. Crown J, Casper ES, Botet J, et al.: Lack of efficacy of high-dose leucovorin and fluorouracil in patients with advanced pancreatic adenocarcinoma. Journal of Clinical Oncology 9(9): 1682-1686, 1991.

  12. Carmichael J, Fink U, Russell RC, et al.: Phase II study of gemcitabine in patients with advanced pancreatic cancer. British Journal of Cancer 73(1): 101-105, 1996.

RECURRENT PANCREATIC CANCER

Chemotherapy occasionally produces objective antitumor response, but the low percentage of significant responses and lack of survival advantage warrant use of therapies under evaluation.[1]

Treatment options:

Standard:

1. Chemotherapy: fluorouracil [2] or gemcitabine.[3,4]

2. Palliative surgical bypass procedures, endoscopic or radiologically placed stents.

3. Palliative radiation procedures.

4. Pain relief by celiac axis nerve or intrapleural block (percutaneous).[5]

5. Other palliative medical care alone.

Under clinical evaluation:
Clinical trials evaluating pharmacologic modulation of fluorinated
pyrimidines, new anticancer agents, or biologicals (phase I and II).

References:

  1. Evans DB, Abbruzzese JL, Rich TA: Cancer of the pancreas. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. Philadelphia, Pa: Lippincott-Raven Publishers, 5th ed., 1997, pp 1054-1087.

  2. Cullinan SA, Moertel CG, Fleming TR, et al.: A comparison of three chemotherapeutic regimens in the treatment of advanced pancreatic and gastric carcinoma. Journal of the American Medical Association 253(14): 2061-2067, 1985.

  3. Rothenberg ML, Moore MJ, Cripps MC, et al.: A phase II trial of gemcitabine in patients with 5-FU-refractory pancreas cancer. Annals of Oncology 7(4): 347-353, 1996.

  4. Burris HA, Moore MJ, Andersen J, et al.: Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial. Journal of Clinical Oncology 15(6): 2403-2413, 1997.

  5. Polati E, Finco G, Gottin L, et al.: Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer. British Journal of Surgery 85(2): 199-201, 1998.

Date Last Modified: 08/1999


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