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Neoadjuvant, adjuvant, and palliative treatment of pancreatic cancer

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Abstract

Pancreatic cancer remains a highly malignant disease. Curative treatment is only possible for patients diagnosed at a very early stage. Therefore, the vast majority of pancreatic cancer patients receive palliative treatment. Surgical palliation is offered to patients who are found not to have a resectable tumor. The treatment of obstructive jaundice is managed by stenting of the common bile duct or by a surgical bypass. The best possible surgical procedure should be based on the factors that influence hospital mortality, length of survival, and quality of life. In patients with a life expectancy of longer than 3 months, surgical bypass is recommended, with hepaticojejunostomy the treatment of choice. In the same surgical procedure, the relief of duodenal obstruction with a gastroenteric bypass should be achieved. Chemotherapy, radiotherapy, or a combination of both is employed as a neoadjuvant measure, as an adjuvant treatment, or, in most patients, as palliation. As palliative chemotherapy alone, 5-fluorouracil (5-FU) plus folinic acid is still the treatment of choice; however, newer drugs, such as gemcitabine, seem to have similar or marginally better results. Palliative radiochemotherapy with external-beam radiation plus 5-FU and folinic acid seems to lead to better local control of tumor progression but not to better survival, for which distant metastases are the limiting factor.

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References and Recommended Reading

  1. Heeckt P, Safi F, Binder T, Büchler M: Free intraperitoneal tumor cells in pancreatic cancer: significance for clinical course and therapy. Chirurg 1992, 63:563–567.

    PubMed  CAS  Google Scholar 

  2. Gerhard M, Juhl H, Kalthoff H, et al.: Specific detection of carcinoembryonic antigen-expressing tumor cells in bone marrow aspirates by polymerase chain reaction. J Clin Oncol 1994, 12:725–729.

    PubMed  CAS  Google Scholar 

  3. Inoue S, Nakao A, Kasai Y, et al.: Detection of hepatic micrometastasis in pancreatic adenocarcinoma patients by two-stage polymerase chain reaction fragment length polymorphism analysis. Jpn J Cancer Res 1995, 86:626–630.

    PubMed  CAS  Google Scholar 

  4. Thorban S, Roder JD, Pantel K, Siewert JR: Immunocytochemical detection of isolated epithelial tumor cells in bone marrow of patients with pancreatic carcinoma. Am J Surg 1996, 172:297–298.

    Article  PubMed  CAS  Google Scholar 

  5. Hosch SB, Knoefel WT, Metz S, et al.: Early lymphatic tumor cell dissemination in pancreatic cancer: frequency and prognostic significance. Pancreas 1997, 15:154–159.

    Article  PubMed  CAS  Google Scholar 

  6. Wagener DJT, de Molder PHM, Wils JA: Multimodality treatment of locally advanced pancreatic cancer. Ann Oncol 1994, 5:81–86.

    PubMed  Google Scholar 

  7. Ohhigashi H.: Survival after intraarterial chemotherapy for pancreatic cancer. In Arterial Infusion Chemotherapy. Edited by Taguchi T, Nakamura H. Tokyo: Journal of Cancer and Chemotherapy Publishing; 1994:416–426.

    Google Scholar 

  8. Andren-Sandberg A, Westerdahl J, Ihse I: Recurrence after pancreatectomy for pancreatic cancer [abstract]. Digestion 1992, 52:67.

    Article  Google Scholar 

  9. Baumel H, Huguier M, Manderscheid JC, Fabre et al.: Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery. Br J Surg 1984, 81:102–107.

    Article  Google Scholar 

  10. Tsuchiya R, Oribe T, Noda T: Size of the tumor and other factors influencing prognosis of carcinoma of the head of the pancreas. Am J Gastroenterol 1985, 80:459–462.

    PubMed  CAS  Google Scholar 

  11. Cameron JL, Crist DW, Sitzmann JV, et al.: Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer. Am J Surg 1991, 161:120–124.

    Article  PubMed  CAS  Google Scholar 

  12. Nagakawa T, Konishi I, Ueno K, et al.: The results and problems of extensive radical surgery for carcinoma of the head of the pancreas. Jpn J Surg 1991, 21:262–267.

    Article  PubMed  CAS  Google Scholar 

  13. Ishikawa O, Ohhigashi H, Sasaki Y, et al.: Practical usefulness of lymphatic and connective tissue clearance for the carcinoma of the pancreas head. Ann Surg 1988, 208:215–220.

    Article  PubMed  CAS  Google Scholar 

  14. Geer RJ, Brennan MF: Prognostic indicators for survival after resection of adenocarcinoma of the pancreas. Am J Surg 1993, 165:68–73.

    Article  PubMed  CAS  Google Scholar 

  15. Yeo CJ, Cameron JL: Improving results of pancreaticoduodenectomy for pancreatic cancer. World J Surg 1999, 23:907–912.

    Article  PubMed  CAS  Google Scholar 

  16. Gall FP, Zirngibl H: Survival after surgical treatment for pancreatic cancer [in German]. In Chirurgische, Onkologische und Sta-diengerechte Therapie Maligner Tumoren. Edited by Gall FP, Hermanek P, Tonak J. Berlin: Springer; 1986:416–460.

    Google Scholar 

  17. Beger HG, Büchler MW, Friess H: Surgical results and indication for adjuvant measures in pancreatic cancer. Chirurg 1994, 65:246–252.

    PubMed  CAS  Google Scholar 

  18. Bornman PC, Harries-Jones EP, Tobias R, et al.: Prospective controlled trial of transhepatic biliary endoprosthesis versus biliary bypass surgery for incurable carcinoma of the head of the pancreas. Lancet 1986, 1:69–71.

    Article  PubMed  CAS  Google Scholar 

  19. Shepherd HA, Royle G, Ross AP, et al.: Endoscopic biliary endoprosthesis in palliation of the malignant obstruction of the distal common bile duct: a randomized trial. Br J Surg 1988, 75:1166–1168.

    Article  PubMed  CAS  Google Scholar 

  20. Andersen JR, Sorensen SM, Kruse A, et al.: Randomized trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice. Gut 1989, 30:1132–1135.

    PubMed  CAS  Google Scholar 

  21. Dowsett JF: Malignant obstructive jaundice: a prospective randomized trial of bypass surgery versus endoscopic stenting [abstract]. Gastroenterology 1989, 96:128A.

    Google Scholar 

  22. Neoptolemos J, Hendrickse C: Palliative bypass for pancreatic cancer. In Standards in Pancreatic Surgery. Edited by Beger HG, Büchler M, Malfertheiner P. Berlin: Springer; 1993:614–630.

    Google Scholar 

  23. Watanapa P, Williamson RC: Surgical palliation for pancreatic cancer. Br J Surg 1992, 79:8–20.

    Article  PubMed  CAS  Google Scholar 

  24. National Cancer Institute: Annual cancer statistics review 1973–1988. Bethesda, MD: Department of Health and Human Services; 1991. NIH Publication 91-2789.

    Google Scholar 

  25. Lillemoe K, Sauter PK, Pitt H, Yeo C, et al.: Current status of surgical palliation of periampullary carcinoma. Surg Gynecol Obstet 1993, 176:1–10.

    PubMed  CAS  Google Scholar 

  26. Schantz SP, Schickler W, Evans T, Coffey RJ: Palliative gastroenterostomy for pancreatic cancer. Am J Surg 1984, 147:793–796.

    Article  PubMed  CAS  Google Scholar 

  27. Sarr MG, Gladen HE, Beart RW Jr, van Heerden JA: Role of gastroenterostomy in patients with unresectable carcinoma of the pancreas. Surg Gynecol Obstet 1981, 152:597–600.

    PubMed  CAS  Google Scholar 

  28. Costamagna G, Alevras P, Palladino F, et al.: Endoscopic pancreatic stenting in pancreatic cancer. Can J Gastroenterol 1999, 13:481–487.

    PubMed  CAS  Google Scholar 

  29. Flanigan DP, Kraft RO: Continuing experience with palliative chemical splanchnicectomy. Arch Surg 1978, 113:509–511.

    PubMed  CAS  Google Scholar 

  30. Lillemoe KD, Cameron JL, Kaufman HS, et al.: Chemical splanchnicectomy in patients with unresectable pancreatic cancer: a prospective randomized trial. Ann Surg 1993, 217:447–457.

    Article  PubMed  CAS  Google Scholar 

  31. Sharfman W, Wals TD: Has the analgesic efficacy of neurolytic celiac plexus block been demonstrated in pancreatic cancer? Pain 1990, 41:267–271.

    Article  PubMed  CAS  Google Scholar 

  32. Sindelar WF, Johnstone PA, Sprague M, et al.: Effects of intraoperative radiotherapy on vascular grafts in a canine model. Int J Radiat Oncol Biol Phys 1994, 29:1015–1025.

    PubMed  Google Scholar 

  33. Link KH, Gansauge F, Pillasch J, Beger HG: Multimodal therapies in ductal pancreatic cancer: the future. Int J Pancreatol 1997, 21:71–83.

    PubMed  CAS  Google Scholar 

  34. Neoptolemos JP, Kerr DJ: Adjuvant therapy for pancreatic cancer. Br J Surg 1995, 82:1012–1014.

    Article  PubMed  CAS  Google Scholar 

  35. Ishikawa O, Ohhigashi H, Sasaki Y, et al.: Liver perfusion chemotherapy via both the hepatic artery and portal vein to prevent hepatic metastasis after extended pancreatectomy for adenocarcinoma of the pancreas. Am J Surg 1994, 168:361–364.

    Article  PubMed  CAS  Google Scholar 

  36. Dobelbower RR, Bronn DG: Radiotherapy in the treatment of pancreatic cancer. Clin Gastroenterol 1990, 4:969–983.

    CAS  Google Scholar 

  37. Zerbi A, Fossat V, Parolini D, et al.: Intraoperative radiation therapy adjuvant to resection in the treatment of pancreatic cancer. Cancer 1994, 73:2930–2395.

    Article  PubMed  CAS  Google Scholar 

  38. Ozaki H: Modern surgical treatment of pancreatic cancer. Int J Pancreatol 1994, 16:121–129.

    PubMed  CAS  Google Scholar 

  39. Bernhard H, Jager AE, Bernhard M, et al.: Treatment of advanced pancreatic cancer with 5-fluorouracil, folinic acid and interferon-alpha 2a: results of a phase II-trial. Br J Cancer 1995, 71:102–105.

    PubMed  CAS  Google Scholar 

  40. Isacoff WH, Reber H, Tompkins R, et al.: Continuous infusion of 5-fluorouracil (5-FU), calcium, leukovorin (LV), mitomycin- C (mito-C) and dipyramidole (D) treatment for patients with locally advanced pancreatic cancer [abstract]. Proc ASCO 1995, 14:198.

    Google Scholar 

  41. 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. J Clin Oncol 1997, 15:2403–2413.

    PubMed  CAS  Google Scholar 

  42. Garton GR, Gunderson LL, Webb MJ, et al.: Intraoperative radiation therapy in gynecologic cancer: update of the experience at a single institution. Int J Radiat Oncol Biol Phys 1997, 37:839–843.

    Article  PubMed  CAS  Google Scholar 

  43. Bruckner HW, Kalnicki S, Dalton J, et al.: Combined modality therapy increasing local control of pancreatic cancer. Cancer Invest 1993, 11:241–246.

    PubMed  CAS  Google Scholar 

  44. Jessup JM, Steele G, Mayer RJ, et al.: Neoadjuvant therapy for unresectable pancreatic adenocarcinoma. Arch Surg 1993, 128:559–564.

    PubMed  CAS  Google Scholar 

  45. Onodera T, Okamoto A, Ito I, Matsuda T: Multimodal treatment for advanced cancer of the pancreas. World J Surg 1981, 5:759–761.

    Article  PubMed  CAS  Google Scholar 

  46. Komaki R, Hansen R, Cox JD, Wilson JF: Phase I-II study of prophylactic hepatic irradiation with local irradiation and systemic chemotherapy for adenocarcinoma of the pancreas. Int J Radiat Oncol Biol Phys 1988, 15:1447–1452.

    PubMed  CAS  Google Scholar 

  47. Komaki R, Wadler S, Peters T, et al.: High-dose local irradiation plus prophylactic hepatic irradiation and chemotherapy for inoperable adenocarcinoma of the pancreas. Cancer 1992, 69:2807–2812.

    Article  PubMed  CAS  Google Scholar 

  48. Bosset JF, Pavy JJ, Gillet M, et al.: Conventional external irradiation alone as adjuvant treatment in resectable pancreatic cancer: results of a prospective study. Radiother Oncol 1992, 24:191–194.

    Article  PubMed  CAS  Google Scholar 

  49. Snady H, Bruckner H, Cooperman A, et al.: Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma: an outcomes trial. Cancer 2000, 89:314–327. Neoadjuvant treatment in advanced disease with chemoradiation led to resectability in 20 of 30 patients. Survival was 23.4 months.

    Article  PubMed  CAS  Google Scholar 

  50. Rozenblum E, Schutte M, Goggins M, et al.: Tumor-suppressive pathways in pancreatic carcinoma. Cancer Res 1997, 57:1731–1734.

    PubMed  CAS  Google Scholar 

  51. Gastrointestinal Tumor Study Group: Further evidence of effective adjuvant combined radiation and chemotherapy following curative resection of pancreatic cancer. Cancer 1987, 59:2006–2010.

    Article  Google Scholar 

  52. Foo ML, Gunderson LL, Nagorney DM, et al.: Patterns of failure in grossly resected pancreatic ductal adenocarcinoma treated with adjuvant irradiation ± 5 fluorouracil. Int J Radiat Oncol Biol Phys 1993, 26:483–489.

    PubMed  CAS  Google Scholar 

  53. Takahashi S, Ogata Y, Miyazaki H, et al.: Aggressive surgery for pancreatic duct cell cancer: feasibility, validity, limitations. World J Surg 1995, 19:653–659.

    Article  PubMed  CAS  Google Scholar 

  54. Yeo CJ, Abrams RA, Grochow LB, et al.: Pancreaticoduodenectomy for pancreatic adenocarcinoma: postoperative adjuvant chemoradiation improves survival: a prospective, single-institution experience. Ann Surg 1997, 225:621–633. Postoperative combined chemo- and radiotherapy (EBRT + 5-FU) increased survival significantly (19.5 vs 13.5 months), according to this report.

    Article  PubMed  CAS  Google Scholar 

  55. Sindelar WF, Kinsella TJ Studies of intraoperative radiotherapy in carcinoma of the pancreas. Ann Oncol 1999, 10(suppl 4):226–230.

    Article  PubMed  Google Scholar 

  56. Beger HG, Gansauge F, Büchler MW, Link KH: Intraarterial adjuvant chemotherapy after pancreaticoduodenectomy for pancreatic cancer: significant reduction in occurrence of liver metastasis. World J Surg 1999, 23:946–949. A significant survival benefit (23 vs 10.5 months) is shown for patients (n=24) who received regional chemotherapy via celiac axis infusion as an adjuvant therapy after resection (UICC I-III).

    Article  PubMed  CAS  Google Scholar 

  57. Spitz FR, Abbruzzese JL, Lee JE, et al.: Preoperative and postoperative chemoradiation strategies in patients treated with pancreaticoduodenectomy for adenocarcinoma of the pancreas. J Clin Oncol 1997, 15:928–937.

    PubMed  CAS  Google Scholar 

  58. Klinkenbijl JH, Jeekel J, Sahmoud T, et al.: Adjuvant radiotherapy and 5-fluorouracil after curative resection of cancer of the pancreas and periampullary region: phase III trial of the EORTC Gastrointestinal Tract Cancer Cooperative Group. Ann Surg 1999, 230:776–782. This large randomized study compared radiochemotherapy (5-FU + EBRT) with observation in an adjuvant setting following tumor resection. The results did not show a significant survival benefit for the treated patients.

    Article  PubMed  CAS  Google Scholar 

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  1. Department of General Surgery, University of Ulm, Steinhoevelstrasse 9, 89075, Ulm, Germany

    Dieter Birk MD & Hans G. Beger MD

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  1. Dieter Birk MD
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Dieter, B., Beger, H.G. Neoadjuvant, adjuvant, and palliative treatment of pancreatic cancer. Curr Gastroenterol Rep 3, 129–135 (2001). https://doi.org/10.1007/s11894-001-0009-4

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