gastrointestinal disorders
Pancreatic Cancer
Treatment of Pancreatic Cancer
Whipple procedure (pancreaticoduodenectomy) Neoadjuvant chemotherapy or combination chemotherapy and radiation therapy (chemoradiation) Symptom control About 80 to 90% of cancers are considered surgically unresectable at time of diagnosis because of metastases or invasion of major blood vessels. For patients undergoing resective surgery, the location of the tumor in the pancreas determines the type of procedure that is done. Tumors in the head of the pancreas are removed with a Whipple procedure. Tumors in the neck, body, or tail are generally removed with distal pancreatectomy, wherein the head of the pancreas is left in situ. Use of neoadjuvant (preoperative) chemotherapy or chemoradiation has become increasingly popular because of the aggressive nature of this disease and because of patient difficulty tolerating chemotherapy after pancreatic surgery. Data from a recent study suggest that neoadjuvant chemotherapy showed a survival benefit in borderline resectable patients ( Treatment references ). In another study, the FOLFIRINOX regimen ( If an unresectable tumor is found at operation and gastroduodenal or bile duct obstruction is present or pending, a double gastric and biliary bypass operation is usually done to relieve obstruction. In patients with inoperable lesions and jaundice, endoscopic placement of a bile duct stent relieves jaundice. Duodenal stenting is frequently done. However, surgical bypass should be considered in patients with unresectable lesions if life expectancy is>6 to 7 months because of complications associated with stents. Analgesics, usually opioids Sometimes procedures to maintain biliary patency Sometimes pancreatic enzyme supplementation Ultimately, most patients experience pain and die. Thus, symptomatic treatment is as important as controlling disease. Appropriate end-of-life care should be discussed (see also The Dying Patient ). Patients with moderate to severe pain should receive an oral opioid in doses adequate to provide relief. Concern about addiction should not be a barrier to effective pain control. For chronic pain, long-acting preparations (eg, transdermalfentanyl,oxycodone,oxymorphone) are usually best. Percutaneous or operative splanchnic (celiac) block effectively controls pain in some patients. In cases of intolerable pain, opioids given subcutaneously or by IV, epidural, or intrathecal infusion provides additional relief. If palliative surgery or endoscopic placement of a biliary stent fails to relieve pruritus secondary to obstructive jaundice, pruritus can be managed withcholestyramine(4 g orally once a day to 4 times a day). Exocrine pancreatic insufficiency is treated with capsules of porcine pancreatic enzymes (pancrelipase). There are a number of commercial products available and the amount of enzyme per capsule varies. The dosage needed varies depending on the patient's symptoms, the degree of steatorrhea, and the fat content of the diet. Optimal intraluminal pH for the enzymes is 8; thus, some clinicians give a proton pump inhibitor or H2 blocker twice a day. Diabetes mellitus should be closely monitored and controlled. 1.Versteijne E, van Dam JL, Suker M, et al: Neoadjuvant Chemoradiotherapy Versus Upfront Surgery for Resectable and Borderline Resectable Pancreatic Cancer: Long-Term Results of the Dutch Randomized PREOPANC Trial.J Clin Oncol40(11):1220-1230, 2022. doi: 10.1200/JCO.21.02233 2.Conroy T, Hammel P, Hebbar M, et al: FOLFIRINOX orGemcitabineas Adjuvant Therapy for Pancreatic Cancer.N Engl J Med379(25):2395-2406, 2018. doi: 10.1056/NEJMoa1809775 3.Sohal DPS, Duong M, Ahmad SA, et al: Efficacy of Perioperative Chemotherapy for Resectable Pancreatic Adenocarcinoma: A Phase 2 Randomized Clinical Trial.JAMA Oncol7(3):421-427, 2021. doi: 10.1001/jamaoncol.2020.7328.Clarification and additional information.JAMA Oncol23:e215278, 2021. doi: 10.1001/jamaoncol.2021.5278 