Pancreatic Cancer

Abstract

• Pancreatic cancer is the ninth most commonly diagnosed cancer and the fourth leading cause of cancer deaths in industrialized countries.

• Early-stage pancreatic cancer usually has no specific symptoms. Common signs and symptoms in advanced diseases include fatigue, weight loss, jaundice, anorexia, diabetes mellitus, and abdominal/back pain.

• Accuracy of clinical diagnosis based on history and physical examination, laboratory and imaging studies (including computed tomography [CT] and endoscopic ultrasound [EUS]) approaches 90%. Tissue diagnosis in unresectable cases is needed before treatment, but its use is controversial in patients slated for surgical resection.

• Stage at diagnosis is the most important prognostic factor and predicts the resectability of a tumor. Overall survival (OS) of patients achieving R0 (complete) resection after radical surgery is ~20%. However, only 15–20% of cases are resectable at diagnosis, and long-term survival of patients with unresectable disease is less than 5%.

• Commonly observed metastatic sites include liver, peritoneum, and lung. Metastasis to bone, brain, and other organs/tissues is uncommon.

• Treatment of pancreatic cancer depends on the stage of disease. Surgery is the only curative treatment for localized diseases. T1, T2, and some T3 pancreatic cancers are resectable. Completeness of resection (R0 versus R1 versus R2 resection) is prognostically important.

• As 80% of cases develop locoregional recurrence after surgery, adjuvant chemoradiation is recommended and is the current standard in the USA. The efficacy of the gemcitabine (GEM) → 5-FU plus radiation therapy → GEM regimen has been demonstrated in the Radiation Therapy Oncology Group (RTOG) 9704 Trial.

• Radiation therapy (with concurrent chemotherapy) plays a major role in locoregionally advanced disease. An optimal treatment regimen is yet to be determined. Results from phase II trials indicated that full-dose GEM concurrent with three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiation therapy (IMRT) is well tolerated and efficacious, with 1-year OS rate approaching 60%.

• GEM-based chemotherapy is the mainstay treatment for metastatic pancreatic cancer. Erlotinib in concurrent with GEM further improves median survival time and OS rate.