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| | ==Physical examination== |
| | ==References== |
| | {{reflist|2}} |
| | |
| | {{WH}} |
| | {{WS}} |
| | |
| | ==References== |
| | {{Reflist|2}} |
| | |
| | |
| | ===Pathophysiology prev=== |
| | <div style="-webkit-user-select: none;"> |
| | {| class="infobox" style="position: fixed; top: 65%; right: 10px; margin: 0 0 0 0; border: 0; float: right;" |
| | |- |
| | | {{#ev:youtube|https://https://www.youtube.com/watch?v=5szNmKtyBW4|350}} |
| | |- |
| | |} |
| __NOTOC__ | | __NOTOC__ |
| {{Pancreatic cancer}} | | {{Cirrhosis}} |
| {{CMG}}; {{AE}} {{Cherry}} | | {{CMG}} {{AE}} |
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| In patients with pancreatic cancer, surgery is the primary modality of treatment.
| | ===Pathophysiology prev=== |
| Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients.Patients with unresectable disease are treated with chemotherapy and/or radiation therapy as a part of adjuvant or neoadjuvant therapy.
| | <div style="-webkit-user-select: none;"> |
| Curative resection is not contraindicated in all patients with vascular invasion.<ref name="pmid17632763">{{cite journal |vauthors=Al-Haddad M, Martin JK, Nguyen J, Pungpapong S, Raimondo M, Woodward T, Kim G, Noh K, Wallace MB |title=Vascular resection and reconstruction for pancreatic malignancy: a single center survival study |journal=J. Gastrointest. Surg. |volume=11 |issue=9 |pages=1168–74 |year=2007 |pmid=17632763 |doi=10.1007/s11605-007-0216-x |url=}}</ref><ref name="pmid21768431">{{cite journal |vauthors=Donahue TR, Isacoff WH, Hines OJ, Tomlinson JS, Farrell JJ, Bhat YM, Garon E, Clerkin B, Reber HA |title=Downstaging chemotherapy and alteration in the classic computed tomography/magnetic resonance imaging signs of vascular involvement in patients with pancreaticobiliary malignant tumors: influence on patient selection for surgery |journal=Arch Surg |volume=146 |issue=7 |pages=836–43 |year=2011 |pmid=21768431 |doi=10.1001/archsurg.2011.152 |url=}}</ref><ref name="pmid15585381">{{cite journal |vauthors=Tseng JF, Raut CP, Lee JE, Pisters PW, Vauthey JN, Abdalla EK, Gomez HF, Sun CC, Crane CH, Wolff RA, Evans DB |title=Pancreaticoduodenectomy with vascular resection: margin status and survival duration |journal=J. Gastrointest. Surg. |volume=8 |issue=8 |pages=935–49; discussion 949–50 |year=2004 |pmid=15585381 |doi=10.1016/j.gassur.2004.09.046 |url=}}</ref><ref name="pmid19221327">{{cite journal |vauthors=Martin RC, Scoggins CR, Egnatashvili V, Staley CA, McMasters KM, Kooby DA |title=Arterial and venous resection for pancreatic adenocarcinoma: operative and long-term outcomes |journal=Arch Surg |volume=144 |issue=2 |pages=154–9 |year=2009 |pmid=19221327 |doi=10.1001/archsurg.2008.547 |url=}}</ref><ref name="pmid22932857">{{cite journal |vauthors=Castleberry AW, White RR, De La Fuente SG, Clary BM, Blazer DG, McCann RL, Pappas TN, Tyler DS, Scarborough JE |title=The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database |journal=Ann. Surg. Oncol. |volume=19 |issue=13 |pages=4068–77 |year=2012 |pmid=22932857 |doi=10.1245/s10434-012-2585-y |url=}}</ref>
| | {| class="infobox" style="position: fixed; top: 65%; right: 10px; margin: 0 0 0 0; border: 0; float: right;" |
| Involvement of the portal or superior mesenteric vein can be resected and reconstructed with the help of splenic, saphenous or internal jugular veins.<ref name="pmid9635805">{{cite journal |vauthors=Leach SD, Lee JE, Charnsangavej C, Cleary KR, Lowy AM, Fenoglio CJ, Pisters PW, Evans DB |title=Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head |journal=Br J Surg |volume=85 |issue=5 |pages=611–7 |year=1998 |pmid=9635805 |doi=10.1046/j.1365-2168.1998.00641.x |url=}}</ref><ref name="pmid8597509">{{cite journal |vauthors=Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR, El-Naggar AK, Fenoglio CJ, Lee JE, Evans DB |title=Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group |journal=Ann. Surg. |volume=223 |issue=2 |pages=154–62 |year=1996 |pmid=8597509 |pmc=1235091 |doi= |url=}}</ref><ref name="pmid22886567">{{cite journal |vauthors=Murakami Y, Uemura K, Sudo T, Hashimoto Y, Nakashima A, Kondo N, Nakagawa N, Sueda T |title=Benefit of portal or superior mesenteric vein resection with adjuvant chemotherapy for patients with pancreatic head carcinoma |journal=J Surg Oncol |volume=107 |issue=4 |pages=414–21 |year=2013 |pmid=22886567 |doi=10.1002/jso.23229 |url=}}</ref><ref name="pmid19156463">{{cite journal |vauthors=Ramacciato G, Mercantini P, Petrucciani N, Giaccaglia V, Nigri G, Ravaioli M, Cescon M, Cucchetti A, Del Gaudio M |title=Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma? |journal=Ann. Surg. Oncol. |volume=16 |issue=4 |pages=817–25 |year=2009 |pmid=19156463 |doi=10.1245/s10434-008-0281-8 |url=}}</ref> However, the involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection.<ref name="pmid22064622">{{cite journal |vauthors=Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J |title=Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis |journal=Ann. Surg. |volume=254 |issue=6 |pages=882–93 |year=2011 |pmid=22064622 |doi=10.1097/SLA.0b013e31823ac299 |url=}}</ref>
| | |- |
| Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications. The facts are discussed by the patient and surgical team before arriving at a well-informed decision.
| | | {{#ev:youtube|https://https://www.youtube.com/watch?v=5szNmKtyBW4|350}} |
| The method of surgical resection depends on the following features:<ref name="pmid25207767">{{cite journal |vauthors=Ryan DP, Hong TS, Bardeesy N |title=Pancreatic adenocarcinoma |journal=N. Engl. J. Med. |volume=371 |issue=11 |pages=1039–49 |year=2014 |pmid=25207767 |doi=10.1056/NEJMra1404198 |url=}}</ref>
| | |- |
| *Locally invasive characteristics of the neoplasm
| | |} |
| *Size
| | __NOTOC__ |
| *Location
| | {{Cirrhosis}} |
| Methods of curative resection options include:
| | {{CMG}} {{AE}} |
| **Distal Pancreatectomy
| |
| *Total pancreatectomy
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| *Pancreaticoduodenectomy, where pylorus may or may not be spared on an individual basis
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| The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms based on a statement passed by the American pancreatic association:<ref name="pmid28948329">{{cite journal |vauthors=Fonseca AL, Fleming JB |title=Surgery for pancreatic cancer: critical radiologic findings for clinical decision making |journal=Abdom Radiol (NY) |volume= |issue= |pages= |year=2017 |pmid=28948329 |doi=10.1007/s00261-017-1332-z |url=}}</ref><ref name="pmid24354378">{{cite journal |vauthors=Al-Hawary MM, Francis IR, Chari ST, Fishman EK, Hough DM, Lu DS, Macari M, Megibow AJ, Miller FH, Mortele KJ, Merchant NB, Minter RM, Tamm EP, Sahani DV, Simeone DM |title=Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association |journal=Radiology |volume=270 |issue=1 |pages=248–60 |year=2014 |pmid=24354378 |doi=10.1148/radiol.13131184 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid23532000">{{cite journal |vauthors=Yamada S, Fujii T, Sugimoto H, Nomoto S, Takeda S, Kodera Y, Nakao A |title=Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines |journal=Pancreas |volume=42 |issue=6 |pages=1004–10 |year=2013 |pmid=23532000 |doi=10.1097/MPA.0b013e31827b2d7c |url=}}</ref><ref name="pmid27247216">{{cite journal |vauthors=Balaban EP, Mangu PB, Khorana AA, Shah MA, Mukherjee S, Crane CH, Javle MM, Eads JR, Allen P, Ko AH, Engebretson A, Herman JM, Strickler JH, Benson AB, Urba S, Yee NS |title=Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=22 |pages=2654–68 |year=2016 |pmid=27247216 |doi=10.1200/JCO.2016.67.5561 |url=}}</ref>
| | == History and Symptoms == |
| *Patient selection is based on:
| |
| **Resection margins
| |
| **High probability of cure
| |
| **Patient's age
| |
| **Comorbidities
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|
| |
| European Society for Medical Oncology (ESMO) has certain guidelines on the treatment of metastatic pancreatic cancer:<ref name="pmid26314780">{{cite journal |vauthors=Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, Seufferlein T, Haustermans K, Van Laethem JL, Conroy T, Arnold D |title=Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up |journal=Ann. Oncol. |volume=26 Suppl 5 |issue= |pages=v56–68 |year=2015 |pmid=26314780 |doi=10.1093/annonc/mdv295 |url=}}</ref><ref name="pmid22997452">{{cite journal |vauthors=Seufferlein T, Bachet JB, Van Cutsem E, Rougier P |title=Pancreatic adenocarcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=23 Suppl 7 |issue= |pages=vii33–40 |year=2012 |pmid=22997452 |doi=10.1093/annonc/mds224 |url=}}</ref><ref name="pmid26122369">{{cite journal |vauthors=Evans DB, George B, Tsai S |title=Non-metastatic Pancreatic Cancer: Resectable, Borderline Resectable, and Locally Advanced-Definitions of Increasing Importance for the Optimal Delivery of Multimodality Therapy |journal=Ann. Surg. Oncol. |volume=22 |issue=11 |pages=3409–13 |year=2015 |pmid=26122369 |doi=10.1245/s10434-015-4649-2 |url=}}</ref><ref name="pmid22997452">{{cite journal |vauthors=Seufferlein T, Bachet JB, Van Cutsem E, Rougier P |title=Pancreatic adenocarcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=23 Suppl 7 |issue= |pages=vii33–40 |year=2012 |pmid=22997452 |doi=10.1093/annonc/mds224 |url=}}</ref><ref name="pmid22997452">{{cite journal |vauthors=Seufferlein T, Bachet JB, Van Cutsem E, Rougier P |title=Pancreatic adenocarcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=23 Suppl 7 |issue= |pages=vii33–40 |year=2012 |pmid=22997452 |doi=10.1093/annonc/mds224 |url=}}</ref><ref name="pmid22997452">{{cite journal |vauthors=Seufferlein T, Bachet JB, Van Cutsem E, Rougier P |title=Pancreatic adenocarcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=23 Suppl 7 |issue= |pages=vii33–40 |year=2012 |pmid=22997452 |doi=10.1093/annonc/mds224 |url=}}</ref>
| |
| *Chemotherapy not preferred
| |
| *Gemcitabine is preferred over 5 FU
| |
| *Treatment is symptomatic with bypass surgery or stent placement for gastric outlet obstruction or obstructive jaundice
| |
|
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| In case of locally advanced disease which is unresectable, the following methods of treatment are preferred:<ref name="pmid25524417">{{cite journal |vauthors=Rombouts SJ, Vogel JA, van Santvoort HC, van Lienden KP, van Hillegersberg R, Busch OR, Besselink MG, Molenaar IQ |title=Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer |journal=Br J Surg |volume=102 |issue=3 |pages=182–93 |year=2015 |pmid=25524417 |doi=10.1002/bjs.9716 |url=}}</ref><ref name="pmid25524417">{{cite journal |vauthors=Rombouts SJ, Vogel JA, van Santvoort HC, van Lienden KP, van Hillegersberg R, Busch OR, Besselink MG, Molenaar IQ |title=Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer |journal=Br J Surg |volume=102 |issue=3 |pages=182–93 |year=2015 |pmid=25524417 |doi=10.1002/bjs.9716 |url=}}</ref>
| |
| Microwave ablation
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| Photodynamic therapy
| |
| Irreversible electroporation
| |
| Photodynamic therapy
| |
| High-intensity focused ultrasound (HIFU)
| |
| Iodine-125–cryosurgery
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| Iodine-125
| |
| Stereotactic body radiation therapy (SBRT)
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| Radiofrequency ablation (RFA)
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|
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|
| CHEMOTHERAPY
| | * History should include: |
| | ** Appearance of bowel movements |
| | ** Travel history |
| | ** Associated symptoms |
| | ** Immune status |
| | ** Woodland exposure |
| | ==References== |
| | {{reflist|2}} |
|
| |
|
| Metastatic disease/ Advanced pancreatic cancer which is unresectable:<ref name="pmid28222309">{{cite journal |vauthors=Irigoyen A, Gallego J, Guillén Ponce C, Vera R, Iranzo V, Ales I, Arévalo S, Pisa A, Martín M, Salud A, Falcó E, Sáenz A, Manzano Mozo JL, Pulido G, Martínez Galán J, Pazo-Cid R, Rivera F, García García T, Serra O, Fernández Parra EM, Hurtado A, Gómez Reina MJ, López Gomez LJ, Martínez Ortega E, Benavides M, Aranda E |title=Gemcitabine-erlotinib versus gemcitabine-erlotinib-capecitabine in the first-line treatment of patients with metastatic pancreatic cancer: Efficacy and safety results of a phase IIb randomised study from the Spanish TTD Collaborative Group |journal=Eur. J. Cancer |volume=75 |issue= |pages=73–82 |year=2017 |pmid=28222309 |doi=10.1016/j.ejca.2016.12.032 |url=}}</ref><ref name="pmid28259610">{{cite journal |vauthors=Middleton G, Palmer DH, Greenhalf W, Ghaneh P, Jackson R, Cox T, Evans A, Shaw VE, Wadsley J, Valle JW, Propper D, Wasan H, Falk S, Cunningham D, Coxon F, Ross P, Madhusudan S, Wadd N, Corrie P, Hickish T, Costello E, Campbell F, Rawcliffe C, Neoptolemos JP |title=Vandetanib plus gemcitabine versus placebo plus gemcitabine in locally advanced or metastatic pancreatic carcinoma (ViP): a prospective, randomised, double-blind, multicentre phase 2 trial |journal=Lancet Oncol. |volume=18 |issue=4 |pages=486–499 |year=2017 |pmid=28259610 |doi=10.1016/S1470-2045(17)30084-0 |url=}}</ref><ref name="pmid28105634">{{cite journal |vauthors=Xia BT, Fu B, Wang J, Kim Y, Ahmad SA, Dhar VK, Levinsky NC, Hanseman DJ, Habib DA, Wilson GC, Smith M, Olowokure OO, Kharofa J, Al Humaidi AH, Choe KA, Abbott DE, Ahmad SA |title=Does radiologic response correlate to pathologic response in patients undergoing neoadjuvant therapy for borderline resectable pancreatic malignancy? |journal=J Surg Oncol |volume=115 |issue=4 |pages=376–383 |year=2017 |pmid=28105634 |doi=10.1002/jso.24538 |url=}}</ref><ref name="pmid27484349">{{cite journal |vauthors=Choi SJ, Kim HJ, Kim JS, Bak YT, Kim JS |title=Radiation recall gastritis secondary to combination of gemcitabine and erlotinib in pancreatic cancer and response to PPI - a case report |journal=BMC Cancer |volume=16 |issue= |pages=588 |year=2016 |pmid=27484349 |pmc=4971692 |doi=10.1186/s12885-016-2616-3 |url=}}</ref><ref name="pmid27358556">{{cite journal |vauthors=Wang Y, Hu GF, Zhang QQ, Tang N, Guo J, Liu LY, Han X, Wang X, Wang ZH |title=Efficacy and safety of gemcitabine plus erlotinib for locally advanced or metastatic pancreatic cancer: a systematic review and meta-analysis |journal=Drug Des Devel Ther |volume=10 |issue= |pages=1961–72 |year=2016 |pmid=27358556 |pmc=4912328 |doi=10.2147/DDDT.S105442 |url=}}</ref><ref name="pmid27139057">{{cite journal |vauthors=Hammel P, Huguet F, van Laethem JL, Goldstein D, Glimelius B, Artru P, Borbath I, Bouché O, Shannon J, André T, Mineur L, Chibaudel B, Bonnetain F, Louvet C |title=Effect of Chemoradiotherapy vs Chemotherapy on Survival in Patients With Locally Advanced Pancreatic Cancer Controlled After 4 Months of Gemcitabine With or Without Erlotinib: The LAP07 Randomized Clinical Trial |journal=JAMA |volume=315 |issue=17 |pages=1844–53 |year=2016 |pmid=27139057 |doi=10.1001/jama.2016.4324 |url=}}</ref><ref name="pmid26929778">{{cite journal |vauthors=Chen J, Kaley K, Garcon MC, Rodriguez T, Saif MW |title=A novel schedule of erlotinib/capecitabine (7/7) as salvage therapy in previously treated advanced pancreatic adenocarcinoma: a case series |journal=Therap Adv Gastroenterol |volume=9 |issue=2 |pages=162–8 |year=2016 |pmid=26929778 |pmc=4749861 |doi=10.1177/1756283X15622779 |url=}}</ref>
| | {{WH}} |
| The National Comprehensive Cancer Network (NCCN) has recommended guidelines for treatment in patients based on their performance status.
| | {{WS}} |
| In order to predict survival of patients in various stages of pancreatic cancer, the performance status of a patient is a major prognostic factor. Patients with poor prognostic factors have poor performance status. This includes-<ref name="pmid22996141">{{cite journal |vauthors=Tas F, Sen F, Odabas H, Kılıc L, Keskın S, Yıldız I |title=Performance status of patients is the major prognostic factor at all stages of pancreatic cancer |journal=Int. J. Clin. Oncol. |volume=18 |issue=5 |pages=839–46 |year=2013 |pmid=22996141 |doi=10.1007/s10147-012-0474-9 |url=}}</ref>
| |
| Metastatic disease
| |
| Large tumor
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| Severe weight loss
| |
| Therapy proposed for patients based on the resectability of disease and performance status is as follows:<ref name="pmid17986845">{{cite journal |vauthors=Brasiūniene B, Juozaityte E |title=The effect of combined treatment methods on survival and toxicity in patients with pancreatic cancer |journal=Medicina (Kaunas) |volume=43 |issue=9 |pages=716–25 |year=2007 |pmid=17986845 |doi= |url=}}</ref><ref name="pmid23474363">{{cite journal |vauthors=Mukherjee S, Hurt CN, Bridgewater J, Falk S, Cummins S, Wasan H, Crosby T, Jephcott C, Roy R, Radhakrishna G, McDonald A, Ray R, Joseph G, Staffurth J, Abrams RA, Griffiths G, Maughan T |title=Gemcitabine-based or capecitabine-based chemoradiotherapy for locally advanced pancreatic cancer (SCALOP): a multicentre, randomised, phase 2 trial |journal=Lancet Oncol. |volume=14 |issue=4 |pages=317–26 |year=2013 |pmid=23474363 |pmc=3620899 |doi=10.1016/S1470-2045(13)70021-4 |url=}}</ref><ref name="pmid28376080">{{cite journal |vauthors=Hurt CN, Falk S, Crosby T, McDonald A, Ray R, Joseph G, Staffurth J, Abrams RA, Griffiths G, Maughan T, Mukherjee S |title=Long-term results and recurrence patterns from SCALOP: a phase II randomised trial of gemcitabine- or capecitabine-based chemoradiation for locally advanced pancreatic cancer |journal=Br. J. Cancer |volume=116 |issue=10 |pages=1264–1270 |year=2017 |pmid=28376080 |pmc=5482737 |doi=10.1038/bjc.2017.95 |url=}}</ref><ref name="pmid19307501">{{cite journal |vauthors=Huguet F, Girard N, Guerche CS, Hennequin C, Mornex F, Azria D |title=Chemoradiotherapy in the management of locally advanced pancreatic carcinoma: a qualitative systematic review |journal=J. Clin. Oncol. |volume=27 |issue=13 |pages=2269–77 |year=2009 |pmid=19307501 |doi=10.1200/JCO.2008.19.7921 |url=}}</ref><ref name="pmid7028759">{{cite journal |vauthors=Hazel JJ, Thirlwell MP, Huggins M, Maksymiuk A, MacFarlane JK |title=Multi-drug chemotherapy with and without radiation for carcinoma of the stomach and pancreas: a prospective randomized trial |journal=J Can Assoc Radiol |volume=32 |issue=3 |pages=164–5 |year=1981 |pmid=7028759 |doi= |url=}}</ref><ref name="pmid18467316">{{cite journal |vauthors=Chauffert B, Mornex F, Bonnetain F, Rougier P, Mariette C, Bouché O, Bosset JF, Aparicio T, Mineur L, Azzedine A, Hammel P, Butel J, Stremsdoerfer N, Maingon P, Bedenne L |title=Phase III trial comparing intensive induction chemoradiotherapy (60 Gy, infusional 5-FU and intermittent cisplatin) followed by maintenance gemcitabine with gemcitabine alone for locally advanced unresectable pancreatic cancer. Definitive results of the 2000-01 FFCD/SFRO study |journal=Ann. Oncol. |volume=19 |issue=9 |pages=1592–9 |year=2008 |pmid=18467316 |doi=10.1093/annonc/mdn281 |url=}}</ref>
| |
| In patients with locally advanced unresectable or metastatic disease with good performance status
| |
| Preferred treatment: FOLFIRINOX<ref name="pmid21561347">{{cite journal |vauthors=Conroy T, Desseigne F, Ychou M, Bouché O, Guimbaud R, Bécouarn Y, Adenis A, Raoul JL, Gourgou-Bourgade S, de la Fouchardière C, Bennouna J, Bachet JB, Khemissa-Akouz F, Péré-Vergé D, Delbaldo C, Assenat E, Chauffert B, Michel P, Montoto-Grillot C, Ducreux M |title=FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer |journal=N. Engl. J. Med. |volume=364 |issue=19 |pages=1817–25 |year=2011 |pmid=21561347 |doi=10.1056/NEJMoa1011923 |url=}}</ref><ref name="pmid22964956">{{cite journal |vauthors=Peddi PF, Lubner S, McWilliams R, Tan BR, Picus J, Sorscher SM, Suresh R, Lockhart AC, Wang J, Menias C, Gao F, Linehan D, Wang-Gillam A |title=Multi-institutional experience with FOLFIRINOX in pancreatic adenocarcinoma |journal=JOP |volume=13 |issue=5 |pages=497–501 |year=2012 |pmid=22964956 |doi= |url=}}</ref><ref name="pmid25037971">{{cite journal |vauthors=Marthey L, Sa-Cunha A, Blanc JF, Gauthier M, Cueff A, Francois E, Trouilloud I, Malka D, Bachet JB, Coriat R, Terrebonne E, De La Fouchardière C, Manfredi S, Solub D, Lécaille C, Thirot Bidault A, Carbonnel F, Taieb J |title=FOLFIRINOX for locally advanced pancreatic adenocarcinoma: results of an AGEO multicenter prospective observational cohort |journal=Ann. Surg. Oncol. |volume=22 |issue=1 |pages=295–301 |year=2015 |pmid=25037971 |doi=10.1245/s10434-014-3898-9 |url=}}</ref><ref name="pmid25358667">{{cite journal |vauthors=Blazer M, Wu C, Goldberg RM, Phillips G, Schmidt C, Muscarella P, Wuthrick E, Williams TM, Reardon J, Ellison EC, Bloomston M, Bekaii-Saab T |title=Neoadjuvant modified (m) FOLFIRINOX for locally advanced unresectable (LAPC) and borderline resectable (BRPC) adenocarcinoma of the pancreas |journal=Ann. Surg. Oncol. |volume=22 |issue=4 |pages=1153–9 |year=2015 |pmid=25358667 |pmc=4373613 |doi=10.1245/s10434-014-4225-1 |url=}}</ref><ref name="pmid25599322">{{cite journal |vauthors=Ferrone CR, Marchegiani G, Hong TS, Ryan DP, Deshpande V, McDonnell EI, Sabbatino F, Santos DD, Allen JN, Blaszkowsky LS, Clark JW, Faris JE, Goyal L, Kwak EL, Murphy JE, Ting DT, Wo JY, Zhu AX, Warshaw AL, Lillemoe KD, Fernández-del Castillo C |title=Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer |journal=Ann. Surg. |volume=261 |issue=1 |pages=12–7 |year=2015 |pmid=25599322 |pmc=4349683 |doi=10.1097/SLA.0000000000000867 |url=}}</ref><ref name="pmid25734581">{{cite journal |vauthors=Mellon EA, Hoffe SE, Springett GM, Frakes JM, Strom TJ, Hodul PJ, Malafa MP, Chuong MD, Shridhar R |title=Long-term outcomes of induction chemotherapy and neoadjuvant stereotactic body radiotherapy for borderline resectable and locally advanced pancreatic adenocarcinoma |journal=Acta Oncol |volume=54 |issue=7 |pages=979–85 |year=2015 |pmid=25734581 |doi=10.3109/0284186X.2015.1004367 |url=}}</ref><ref name="pmid26065868">{{cite journal |vauthors=Sadot E, Doussot A, O'Reilly EM, Lowery MA, Goodman KA, Do RK, Tang LH, Gönen M, D'Angelica MI, DeMatteo RP, Kingham TP, Jarnagin WR, Allen PJ |title=FOLFIRINOX Induction Therapy for Stage 3 Pancreatic Adenocarcinoma |journal=Ann. Surg. Oncol. |volume=22 |issue=11 |pages=3512–21 |year=2015 |pmid=26065868 |pmc=4849545 |doi=10.1245/s10434-015-4647-4 |url=}}</ref><ref name="pmid27022826">{{cite journal |vauthors=Stein SM, James ES, Deng Y, Cong X, Kortmansky JS, Li J, Staugaard C, Indukala D, Boustani AM, Patel V, Cha CH, Salem RR, Chang B, Hochster HS, Lacy J |title=Final analysis of a phase II study of modified FOLFIRINOX in locally advanced and metastatic pancreatic cancer |journal=Br. J. Cancer |volume=114 |issue=7 |pages=737–43 |year=2016 |pmid=27022826 |pmc=4984865 |doi=10.1038/bjc.2016.45 |url=}}</ref><ref name="pmid27160474">{{cite journal |vauthors=Suker M, Beumer BR, Sadot E, Marthey L, Faris JE, Mellon EA, El-Rayes BF, Wang-Gillam A, Lacy J, Hosein PJ, Moorcraft SY, Conroy T, Hohla F, Allen P, Taieb J, Hong TS, Shridhar R, Chau I, van Eijck CH, Koerkamp BG |title=FOLFIRINOX for locally advanced pancreatic cancer: a systematic review and patient-level meta-analysis |journal=Lancet Oncol. |volume=17 |issue=6 |pages=801–810 |year=2016 |pmid=27160474 |pmc=5527756 |doi=10.1016/S1470-2045(16)00172-8 |url=}}</ref><ref name="pmid27160474">{{cite journal |vauthors=Suker M, Beumer BR, Sadot E, Marthey L, Faris JE, Mellon EA, El-Rayes BF, Wang-Gillam A, Lacy J, Hosein PJ, Moorcraft SY, Conroy T, Hohla F, Allen P, Taieb J, Hong TS, Shridhar R, Chau I, van Eijck CH, Koerkamp BG |title=FOLFIRINOX for locally advanced pancreatic cancer: a systematic review and patient-level meta-analysis |journal=Lancet Oncol. |volume=17 |issue=6 |pages=801–810 |year=2016 |pmid=27160474 |pmc=5527756 |doi=10.1016/S1470-2045(16)00172-8 |url=}}</ref><ref name="pmid25599322">{{cite journal |vauthors=Ferrone CR, Marchegiani G, Hong TS, Ryan DP, Deshpande V, McDonnell EI, Sabbatino F, Santos DD, Allen JN, Blaszkowsky LS, Clark JW, Faris JE, Goyal L, Kwak EL, Murphy JE, Ting DT, Wo JY, Zhu AX, Warshaw AL, Lillemoe KD, Fernández-del Castillo C |title=Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer |journal=Ann. Surg. |volume=261 |issue=1 |pages=12–7 |year=2015 |pmid=25599322 |pmc=4349683 |doi=10.1097/SLA.0000000000000867 |url=}}</ref><ref name="pmid27160474">{{cite journal |vauthors=Suker M, Beumer BR, Sadot E, Marthey L, Faris JE, Mellon EA, El-Rayes BF, Wang-Gillam A, Lacy J, Hosein PJ, Moorcraft SY, Conroy T, Hohla F, Allen P, Taieb J, Hong TS, Shridhar R, Chau I, van Eijck CH, Koerkamp BG |title=FOLFIRINOX for locally advanced pancreatic cancer: a systematic review and patient-level meta-analysis |journal=Lancet Oncol. |volume=17 |issue=6 |pages=801–810 |year=2016 |pmid=27160474 |pmc=5527756 |doi=10.1016/S1470-2045(16)00172-8 |url=}}</ref>
| |
| In patients with locally advanced unresectable or metastatic disease with good performance status with intolerance to FOLFIRINOX
| |
| Preferred treatment:Paclitaxel protein bound+ Gemcitabine
| |
| In patients with locally advanced unresectable or metastatic disease with poor performance status
| |
| Preferred treatment: Gemcitabine monotherapy<ref name="pmid15908661">{{cite journal |vauthors=Louvet C, Labianca R, Hammel P, Lledo G, Zampino MG, André T, Zaniboni A, Ducreux M, Aitini E, Taïeb J, Faroux R, Lepere C, de Gramont A |title=Gemcitabine in combination with oxaliplatin compared with gemcitabine alone in locally advanced or metastatic pancreatic cancer: results of a GERCOR and GISCAD phase III trial |journal=J. Clin. Oncol. |volume=23 |issue=15 |pages=3509–16 |year=2005 |pmid=15908661 |doi=10.1200/JCO.2005.06.023 |url=}}</ref><ref name="pmid15084616">{{cite journal |vauthors=Van Cutsem E, van de Velde H, Karasek P, Oettle H, Vervenne WL, Szawlowski A, Schoffski P, Post S, Verslype C, Neumann H, Safran H, Humblet Y, Perez Ruixo J, Ma Y, Von Hoff D |title=Phase III trial of gemcitabine plus tipifarnib compared with gemcitabine plus placebo in advanced pancreatic cancer |journal=J. Clin. Oncol. |volume=22 |issue=8 |pages=1430–8 |year=2004 |pmid=15084616 |doi=10.1200/JCO.2004.10.112 |url=}}</ref><ref name="pmid15365074">{{cite journal |vauthors=Rocha Lima CM, Green MR, Rotche R, Miller WH, Jeffrey GM, Cisar LA, Morganti A, Orlando N, Gruia G, Miller LL |title=Irinotecan plus gemcitabine results in no survival advantage compared with gemcitabine monotherapy in patients with locally advanced or metastatic pancreatic cancer despite increased tumor response rate |journal=J. Clin. Oncol. |volume=22 |issue=18 |pages=3776–83 |year=2004 |pmid=15365074 |doi=10.1200/JCO.2004.12.082 |url=}}</ref><ref name="pmid20185458">{{cite journal |vauthors=Ishii H, Furuse J, Boku N, Okusaka T, Ikeda M, Ohkawa S, Fukutomi A, Hamamoto Y, Nakamura K, Fukuda H |title=Phase II study of gemcitabine chemotherapy alone for locally advanced pancreatic carcinoma: JCOG0506 |journal=Jpn. J. Clin. Oncol. |volume=40 |issue=6 |pages=573–9 |year=2010 |pmid=20185458 |doi=10.1093/jjco/hyq011 |url=}}</ref>
| |
| In patients with locally advanced unresectable or metastatic disease with poor performance status refractory to Gemcitabine:
| |
| Preferred treatment: Capecitabine or capecitabine+erlotinib<ref name="pmid17947726">{{cite journal |vauthors=Kulke MH, Blaszkowsky LS, Ryan DP, Clark JW, Meyerhardt JA, Zhu AX, Enzinger PC, Kwak EL, Muzikansky A, Lawrence C, Fuchs CS |title=Capecitabine plus erlotinib in gemcitabine-refractory advanced pancreatic cancer |journal=J. Clin. Oncol. |volume=25 |issue=30 |pages=4787–92 |year=2007 |pmid=17947726 |doi=10.1200/JCO.2007.11.8521 |url=}}</ref>
| |
| One year survival of FOLFIRINOX (leucovorin+5-lfuorouracil [LV5-FU]+oxaliplatin+irinotecan)>Gemcitabine<ref name="pmid23341367">{{cite journal |vauthors=Conroy T, Gavoille C, Samalin E, Ychou M, Ducreux M |title=The role of the FOLFIRINOX regimen for advanced pancreatic cancer |journal=Curr Oncol Rep |volume=15 |issue=2 |pages=182–9 |year=2013 |pmid=23341367 |doi=10.1007/s11912-012-0290-4 |url=}}</ref><ref name="pmid23955427">{{cite journal |vauthors=Boone BA, Steve J, Krasinskas AM, Zureikat AH, Lembersky BC, Gibson MK, Stoller RG, Zeh HJ, Bahary N |title=Outcomes with FOLFIRINOX for borderline resectable and locally unresectable pancreatic cancer |journal=J Surg Oncol |volume=108 |issue=4 |pages=236–41 |year=2013 |pmid=23955427 |pmc=3816713 |doi=10.1002/jso.23392 |url=}}</ref><ref name="pmid15718320">{{cite journal |vauthors=Conroy T, Paillot B, François E, Bugat R, Jacob JH, Stein U, Nasca S, Metges JP, Rixe O, Michel P, Magherini E, Hua A, Deplanque G |title=Irinotecan plus oxaliplatin and leucovorin-modulated fluorouracil in advanced pancreatic cancer--a Groupe Tumeurs Digestives of the Federation Nationale des Centres de Lutte Contre le Cancer study |journal=J. Clin. Oncol. |volume=23 |issue=6 |pages=1228–36 |year=2005 |pmid=15718320 |doi=10.1200/JCO.2005.06.050 |url=}}</ref><ref name="pmid22964956">{{cite journal |vauthors=Peddi PF, Lubner S, McWilliams R, Tan BR, Picus J, Sorscher SM, Suresh R, Lockhart AC, Wang J, Menias C, Gao F, Linehan D, Wang-Gillam A |title=Multi-institutional experience with FOLFIRINOX in pancreatic adenocarcinoma |journal=JOP |volume=13 |issue=5 |pages=497–501 |year=2012 |pmid=22964956 |doi= |url=}}</ref><ref name="pmid12007953">{{cite journal |vauthors=Shinchi H, Takao S, Noma H, Matsuo Y, Mataki Y, Mori S, Aikou T |title=Length and quality of survival after external-beam radiotherapy with concurrent continuous 5-fluorouracil infusion for locally unresectable pancreatic cancer |journal=Int. J. Radiat. Oncol. Biol. Phys. |volume=53 |issue=1 |pages=146–50 |year=2002 |pmid=12007953 |doi= |url=}}</ref><ref name="pmid426553">{{cite journal |vauthors= |title=A multi-institutional comparative trial of radiation therapy alone and in combination with 5-fluorouracil for locally unresectable pancreatic carcinoma. The Gastrointestinal Tumor Study Group |journal=Ann. Surg. |volume=189 |issue=2 |pages=205–8 |year=1979 |pmid=426553 |pmc=1397020 |doi= |url=}}</ref><ref name="pmid23657686">{{cite journal |vauthors=Faris JE, Blaszkowsky LS, McDermott S, Guimaraes AR, Szymonifka J, Huynh MA, Ferrone CR, Wargo JA, Allen JN, Dias LE, Kwak EL, Lillemoe KD, Thayer SP, Murphy JE, Zhu AX, Sahani DV, Wo JY, Clark JW, Fernandez-del Castillo C, Ryan DP, Hong TS |title=FOLFIRINOX in locally advanced pancreatic cancer: the Massachusetts General Hospital Cancer Center experience |journal=Oncologist |volume=18 |issue=5 |pages=543–8 |year=2013 |pmid=23657686 |pmc=3662845 |doi=10.1634/theoncologist.2012-0435 |url=}}</ref>
| |
| One year survival of Gemcitabine+ Erlotinib> Gemcitabine<ref name="pmid28541474">{{cite journal |vauthors=Furuse J, Gemma A, Ichikawa W, Okusaka T, Seki A, Ishii T |title=Postmarketing surveillance study of erlotinib plus gemcitabine for pancreatic cancer in Japan: POLARIS final analysis |journal=Jpn. J. Clin. Oncol. |volume=47 |issue=9 |pages=832–839 |year=2017 |pmid=28541474 |doi=10.1093/jjco/hyx075 |url=}}</ref><ref name="pmid28702772">{{cite journal |vauthors=Fountzilas C, Chhatrala R, Khushalani N, Tan W, LeVea C, Hutson A, Tucker C, Ma WW, Warren G, Boland P, Iyer R |title=A phase II trial of erlotinib monotherapy in advanced pancreatic cancer as a first- or second-line agent |journal=Cancer Chemother. Pharmacol. |volume= |issue= |pages= |year=2017 |pmid=28702772 |doi=10.1007/s00280-017-3375-9 |url=}}</ref><ref name="pmid27139057">{{cite journal |vauthors=Hammel P, Huguet F, van Laethem JL, Goldstein D, Glimelius B, Artru P, Borbath I, Bouché O, Shannon J, André T, Mineur L, Chibaudel B, Bonnetain F, Louvet C |title=Effect of Chemoradiotherapy vs Chemotherapy on Survival in Patients With Locally Advanced Pancreatic Cancer Controlled After 4 Months of Gemcitabine With or Without Erlotinib: The LAP07 Randomized Clinical Trial |journal=JAMA |volume=315 |issue=17 |pages=1844–53 |year=2016 |pmid=27139057 |doi=10.1001/jama.2016.4324 |url=}}</ref><ref name="pmid27139057">{{cite journal |vauthors=Hammel P, Huguet F, van Laethem JL, Goldstein D, Glimelius B, Artru P, Borbath I, Bouché O, Shannon J, André T, Mineur L, Chibaudel B, Bonnetain F, Louvet C |title=Effect of Chemoradiotherapy vs Chemotherapy on Survival in Patients With Locally Advanced Pancreatic Cancer Controlled After 4 Months of Gemcitabine With or Without Erlotinib: The LAP07 Randomized Clinical Trial |journal=JAMA |volume=315 |issue=17 |pages=1844–53 |year=2016 |pmid=27139057 |doi=10.1001/jama.2016.4324 |url=}}</ref>
| |
| One year survival of Gemcitabine+ Capecitabine≥Gemcitabine <ref name="pmid18669454">{{cite journal |vauthors=Bernhard J, Dietrich D, Scheithauer W, Gerber D, Bodoky G, Ruhstaller T, Glimelius B, Bajetta E, Schüller J, Saletti P, Bauer J, Figer A, Pestalozzi BC, Köhne CH, Mingrone W, Stemmer SM, Tàmas K, Kornek GV, Koeberle D, Herrmann R |title=Clinical benefit and quality of life in patients with advanced pancreatic cancer receiving gemcitabine plus capecitabine versus gemcitabine alone: a randomized multicenter phase III clinical trial--SAKK 44/00-CECOG/PAN.1.3.001 |journal=J. Clin. Oncol. |volume=26 |issue=22 |pages=3695–701 |year=2008 |pmid=18669454 |doi=10.1200/JCO.2007.15.6240 |url=}}</ref><ref name="pmid19858379">{{cite journal |vauthors=Cunningham D, Chau I, Stocken DD, Valle JW, Smith D, Steward W, Harper PG, Dunn J, Tudur-Smith C, West J, Falk S, Crellin A, Adab F, Thompson J, Leonard P, Ostrowski J, Eatock M, Scheithauer W, Herrmann R, Neoptolemos JP |title=Phase III randomized comparison of gemcitabine versus gemcitabine plus capecitabine in patients with advanced pancreatic cancer |journal=J. Clin. Oncol. |volume=27 |issue=33 |pages=5513–8 |year=2009 |pmid=19858379 |doi=10.1200/JCO.2009.24.2446 |url=}}</ref><ref name="pmid20817204">{{cite journal |vauthors=Sahora K, Kuehrer I, Eisenhut A, Akan B, Koellblinger C, Goetzinger P, Teleky B, Jakesz R, Peck-Radosavljevic M, Ba'ssalamah A, Zielinski C, Gnant M |title=NeoGemOx: Gemcitabine and oxaliplatin as neoadjuvant treatment for locally advanced, nonmetastasized pancreatic cancer |journal=Surgery |volume=149 |issue=3 |pages=311–20 |year=2011 |pmid=20817204 |doi=10.1016/j.surg.2010.07.048 |url=}}</ref><ref name="pmid23474363">{{cite journal |vauthors=Mukherjee S, Hurt CN, Bridgewater J, Falk S, Cummins S, Wasan H, Crosby T, Jephcott C, Roy R, Radhakrishna G, McDonald A, Ray R, Joseph G, Staffurth J, Abrams RA, Griffiths G, Maughan T |title=Gemcitabine-based or capecitabine-based chemoradiotherapy for locally advanced pancreatic cancer (SCALOP): a multicentre, randomised, phase 2 trial |journal=Lancet Oncol. |volume=14 |issue=4 |pages=317–26 |year=2013 |pmid=23474363 |pmc=3620899 |doi=10.1016/S1470-2045(13)70021-4 |url=}}</ref><ref name="pmid21213060">{{cite journal |vauthors=Stokes JB, Nolan NJ, Stelow EB, Walters DM, Weiss GR, de Lange EE, Rich TA, Adams RB, Bauer TW |title=Preoperative capecitabine and concurrent radiation for borderline resectable pancreatic cancer |journal=Ann. Surg. Oncol. |volume=18 |issue=3 |pages=619–27 |year=2011 |pmid=21213060 |doi=10.1245/s10434-010-1456-7 |url=}}</ref>
| |
| One year survival of Gemcitabine+ nanoparticle albumin-bound (nab)-paclitaxel> Gemcitabine<ref name="pmid28820270">{{cite journal |vauthors=Passero FC, Saif MW |title=Second line treatment options for pancreatic cancer |journal=Expert Opin Pharmacother |volume=18 |issue=15 |pages=1607–1617 |year=2017 |pmid=28820270 |doi=10.1080/14656566.2017.1369955 |url=}}</ref><ref name="pmid24939470">{{cite journal |vauthors=Saif MW |title=Advanced stage pancreatic cancer: novel therapeutic options |journal=Expert Rev Clin Pharmacol |volume=7 |issue=4 |pages=487–98 |year=2014 |pmid=24939470 |doi=10.1586/17512433.2014.910451 |url=}}</ref>
| |
|
| |
|
| | ==Other Imaging Findings== |
| | * [[Endoscopy]] |
| | * [[Barium enema]] |
| | * [[Colonoscopy]] |
| | * [[Sigmoidoscopy]] |
|
| |
|
| NEW TREATMENTS
| | ==Other diagnostic studies== |
| Irinotecan in an encapsulated form inside a nanoliposome is being used in advanced pancreatic cancer patients who have been earlier been treated using gemcitabine-based chemotherapy. <ref name="pmid27140876">{{cite journal |vauthors=Chiang NJ, Chang JY, Shan YS, Chen LT |title=Development of nanoliposomal irinotecan (nal-IRI, MM-398, PEP02) in the management of metastatic pancreatic cancer |journal=Expert Opin Pharmacother |volume=17 |issue=10 |pages=1413–20 |year=2016 |pmid=27140876 |doi=10.1080/14656566.2016.1183646 |url=}}</ref>
| | == Other Diagnostic Studies == |
| Liposomal Irinotecan is used along with leucovorin and fluorouracil.<ref name="pmid26615328">{{cite journal |vauthors=Wang-Gillam A, Li CP, Bodoky G, Dean A, Shan YS, Jameson G, Macarulla T, Lee KH, Cunningham D, Blanc JF, Hubner RA, Chiu CF, Schwartsmann G, Siveke JT, Braiteh F, Moyo V, Belanger B, Dhindsa N, Bayever E, Von Hoff DD, Chen LT |title=Nanoliposomal irinotecan with fluorouracil and folinic acid in metastatic pancreatic cancer after previous gemcitabine-based therapy (NAPOLI-1): a global, randomised, open-label, phase 3 trial |journal=Lancet |volume=387 |issue=10018 |pages=545–57 |year=2016 |pmid=26615328 |doi=10.1016/S0140-6736(15)00986-1 |url=}}</ref>
| |
|
| |
|
| | * Breath hydrogen test |
|
| |
|
| ADJUVANT THERAPY
| | * [[HIV test]]ing for those patients suspected of having HIV |
| The use of gemcitabine as adjuvant therapy is considered a standard form of therapy following surgical resection in pancreatic cancer patients.<ref name="pmid4015380">{{cite journal |vauthors=Kalser MH, Ellenberg SS |title=Pancreatic cancer. Adjuvant combined radiation and chemotherapy following curative resection |journal=Arch Surg |volume=120 |issue=8 |pages=899–903 |year=1985 |pmid=4015380 |doi= |url=}}</ref><ref name="pmid15028824">{{cite journal |vauthors=Neoptolemos JP, Stocken DD, Friess H, Bassi C, Dunn JA, Hickey H, Beger H, Fernandez-Cruz L, Dervenis C, Lacaine F, Falconi M, Pederzoli P, Pap A, Spooner D, Kerr DJ, Büchler MW |title=A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer |journal=N. Engl. J. Med. |volume=350 |issue=12 |pages=1200–10 |year=2004 |pmid=15028824 |doi=10.1056/NEJMoa032295 |url=}}</ref><ref name="pmid20083754">{{cite journal |vauthors=Yang R, Cheung MC, Byrne MM, Jin X, Montero AJ, Jones C, Koniaris LG |title=Survival effects of adjuvant chemoradiotherapy after resection for pancreatic carcinoma |journal=Arch Surg |volume=145 |issue=1 |pages=49–56 |year=2010 |pmid=20083754 |doi=10.1001/archsurg.2009.244 |url=}}</ref><ref name="pmid17227978">{{cite journal |vauthors=Oettle H, Post S, Neuhaus P, Gellert K, Langrehr J, Ridwelski K, Schramm H, Fahlke J, Zuelke C, Burkart C, Gutberlet K, Kettner E, Schmalenberg H, Weigang-Koehler K, Bechstein WO, Niedergethmann M, Schmidt-Wolf I, Roll L, Doerken B, Riess H |title=Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial |journal=JAMA |volume=297 |issue=3 |pages=267–77 |year=2007 |pmid=17227978 |doi=10.1001/jama.297.3.267 |url=}}</ref><ref name="pmid24035532">{{cite journal |vauthors=Liao WC, Chien KL, Lin YL, Wu MS, Lin JT, Wang HP, Tu YK |title=Adjuvant treatments for resected pancreatic adenocarcinoma: a systematic review and network meta-analysis |journal=Lancet Oncol. |volume=14 |issue=11 |pages=1095–103 |year=2013 |pmid=24035532 |doi=10.1016/S1470-2045(13)70388-7 |url=}}</ref><ref name="pmid24419109">{{cite journal |vauthors=Valle JW, Palmer D, Jackson R, Cox T, Neoptolemos JP, Ghaneh P, Rawcliffe CL, Bassi C, Stocken DD, Cunningham D, O'Reilly D, Goldstein D, Robinson BA, Karapetis C, Scarfe A, Lacaine F, Sand J, Izbicki JR, Mayerle J, Dervenis C, Oláh A, Butturini G, Lind PA, Middleton MR, Anthoney A, Sumpter K, Carter R, Büchler MW |title=Optimal duration and timing of adjuvant chemotherapy after definitive surgery for ductal adenocarcinoma of the pancreas: ongoing lessons from the ESPAC-3 study |journal=J. Clin. Oncol. |volume=32 |issue=6 |pages=504–12 |year=2014 |pmid=24419109 |doi=10.1200/JCO.2013.50.7657 |url=}}</ref><ref name="pmid27328270">{{cite journal |vauthors=Mirkin KA, Greenleaf EK, Hollenbeak CS, Wong J |title=Time to the initiation of adjuvant chemotherapy does not impact survival in patients with resected pancreatic cancer |journal=Cancer |volume=122 |issue=19 |pages=2979–87 |year=2016 |pmid=27328270 |doi=10.1002/cncr.30163 |url=}}</ref><ref name="pmid28129987">{{cite journal |vauthors=Neoptolemos JP, Palmer DH, Ghaneh P, Psarelli EE, Valle JW, Halloran CM, Faluyi O, O'Reilly DA, Cunningham D, Wadsley J, Darby S, Meyer T, Gillmore R, Anthoney A, Lind P, Glimelius B, Falk S, Izbicki JR, Middleton GW, Cummins S, Ross PJ, Wasan H, McDonald A, Crosby T, Ma YT, Patel K, Sherriff D, Soomal R, Borg D, Sothi S, Hammel P, Hackert T, Jackson R, Büchler MW |title=Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial |journal=Lancet |volume=389 |issue=10073 |pages=1011–1024 |year=2017 |pmid=28129987 |doi=10.1016/S0140-6736(16)32409-6 |url=}}</ref>
| |
| NEOADJUVANT THERAPY
| |
| Neoadjuvant therapy may be used as a form of therapy due to the following reasons:<ref name="pmid9850029">{{cite journal |vauthors=Pisters PW, Abbruzzese JL, Janjan NA, Cleary KR, Charnsangavej C, Goswitz MS, Rich TA, Raijman I, Wolff RA, Lenzi R, Lee JE, Evans DB |title=Rapid-fractionation preoperative chemoradiation, pancreaticoduodenectomy, and intraoperative radiation therapy for resectable pancreatic adenocarcinoma |journal=J. Clin. Oncol. |volume=16 |issue=12 |pages=3843–50 |year=1998 |pmid=9850029 |doi=10.1200/JCO.1998.16.12.3843 |url=}}</ref><ref name="pmid12011133">{{cite journal |vauthors=Pisters PW, Wolff RA, Janjan NA, Cleary KR, Charnsangavej C, Crane CN, Lenzi R, Vauthey JN, Lee JE, Abbruzzese JL, Evans DB |title=Preoperative paclitaxel and concurrent rapid-fractionation radiation for resectable pancreatic adenocarcinoma: toxicities, histologic response rates, and event-free outcome |journal=J. Clin. Oncol. |volume=20 |issue=10 |pages=2537–44 |year=2002 |pmid=12011133 |doi=10.1200/JCO.2002.11.064 |url=}}</ref><ref name="pmid24306217">{{cite journal |vauthors=Kadera BE, Sunjaya DB, Isacoff WH, Li L, Hines OJ, Tomlinson JS, Dawson DW, Rochefort MM, Donald GW, Clerkin BM, Reber HA, Donahue TR |title=Locally advanced pancreatic cancer: association between prolonged preoperative treatment and lymph-node negativity and overall survival |journal=JAMA Surg |volume=149 |issue=2 |pages=145–53 |year=2014 |pmid=24306217 |doi=10.1001/jamasurg.2013.2690 |url=}}</ref><ref name="pmid21969502">{{cite journal |vauthors=Loehrer PJ, Feng Y, Cardenes H, Wagner L, Brell JM, Cella D, Flynn P, Ramanathan RK, Crane CH, Alberts SR, Benson AB |title=Gemcitabine alone versus gemcitabine plus radiotherapy in patients with locally advanced pancreatic cancer: an Eastern Cooperative Oncology Group trial |journal=J. Clin. Oncol. |volume=29 |issue=31 |pages=4105–12 |year=2011 |pmid=21969502 |pmc=3525836 |doi=10.1200/JCO.2011.34.8904 |url=}}</ref><ref name="pmid28105634">{{cite journal |vauthors=Xia BT, Fu B, Wang J, Kim Y, Ahmad SA, Dhar VK, Levinsky NC, Hanseman DJ, Habib DA, Wilson GC, Smith M, Olowokure OO, Kharofa J, Al Humaidi AH, Choe KA, Abbott DE, Ahmad SA |title=Does radiologic response correlate to pathologic response in patients undergoing neoadjuvant therapy for borderline resectable pancreatic malignancy? |journal=J Surg Oncol |volume=115 |issue=4 |pages=376–383 |year=2017 |pmid=28105634 |doi=10.1002/jso.24538 |url=}}</ref><ref name="pmid25599322">{{cite journal |vauthors=Ferrone CR, Marchegiani G, Hong TS, Ryan DP, Deshpande V, McDonnell EI, Sabbatino F, Santos DD, Allen JN, Blaszkowsky LS, Clark JW, Faris JE, Goyal L, Kwak EL, Murphy JE, Ting DT, Wo JY, Zhu AX, Warshaw AL, Lillemoe KD, Fernández-del Castillo C |title=Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer |journal=Ann. Surg. |volume=261 |issue=1 |pages=12–7 |year=2015 |pmid=25599322 |pmc=4349683 |doi=10.1097/SLA.0000000000000867 |url=}}</ref><ref name="pmid23838925">{{cite journal |vauthors=Motoi F, Ishida K, Fujishima F, Ottomo S, Oikawa M, Okada T, Shimamura H, Takemura S, Ono F, Akada M, Nakagawa K, Katayose Y, Egawa S, Unno M |title=Neoadjuvant chemotherapy with gemcitabine and S-1 for resectable and borderline pancreatic ductal adenocarcinoma: results from a prospective multi-institutional phase 2 trial |journal=Ann. Surg. Oncol. |volume=20 |issue=12 |pages=3794–801 |year=2013 |pmid=23838925 |doi=10.1245/s10434-013-3129-9 |url=}}</ref><ref name="pmid20817204">{{cite journal |vauthors=Sahora K, Kuehrer I, Eisenhut A, Akan B, Koellblinger C, Goetzinger P, Teleky B, Jakesz R, Peck-Radosavljevic M, Ba'ssalamah A, Zielinski C, Gnant M |title=NeoGemOx: Gemcitabine and oxaliplatin as neoadjuvant treatment for locally advanced, nonmetastasized pancreatic cancer |journal=Surgery |volume=149 |issue=3 |pages=311–20 |year=2011 |pmid=20817204 |doi=10.1016/j.surg.2010.07.048 |url=}}</ref><ref name="pmid19307501">{{cite journal |vauthors=Huguet F, Girard N, Guerche CS, Hennequin C, Mornex F, Azria D |title=Chemoradiotherapy in the management of locally advanced pancreatic carcinoma: a qualitative systematic review |journal=J. Clin. Oncol. |volume=27 |issue=13 |pages=2269–77 |year=2009 |pmid=19307501 |doi=10.1200/JCO.2008.19.7921 |url=}}</ref><ref name="pmid20422030">{{cite journal |vauthors=Gillen S, Schuster T, Meyer Zum Büschenfelde C, Friess H, Kleeff J |title=Preoperative/neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of response and resection percentages |journal=PLoS Med. |volume=7 |issue=4 |pages=e1000267 |year=2010 |pmid=20422030 |pmc=2857873 |doi=10.1371/journal.pmed.1000267 |url=}}</ref><ref name="pmid22012027">{{cite journal |vauthors=Andriulli A, Festa V, Botteri E, Valvano MR, Koch M, Bassi C, Maisonneuve P, Sebastiano PD |title=Neoadjuvant/preoperative gemcitabine for patients with localized pancreatic cancer: a meta-analysis of prospective studies |journal=Ann. Surg. Oncol. |volume=19 |issue=5 |pages=1644–62 |year=2012 |pmid=22012027 |doi=10.1245/s10434-011-2110-8 |url=}}</ref><ref name="pmid18308215">{{cite journal |vauthors=Greer SE, Pipas JM, Sutton JE, Zaki BI, Tsapakos M, Colacchio TA, Gibson JJ, Wiener DC, Ripple GH, Barth RJ |title=Effect of neoadjuvant therapy on local recurrence after resection of pancreatic adenocarcinoma |journal=J. Am. Coll. Surg. |volume=206 |issue=3 |pages=451–7 |year=2008 |pmid=18308215 |doi=10.1016/j.jamcollsurg.2007.10.002 |url=}}</ref><ref name="pmid12399067">{{cite journal |vauthors=Kim HJ, Czischke K, Brennan MF, Conlon KC |title=Does neoadjuvant chemoradiation downstage locally advanced pancreatic cancer? |journal=J. Gastrointest. Surg. |volume=6 |issue=5 |pages=763–9 |year=2002 |pmid=12399067 |doi= |url=}}</ref><ref name="pmid10487547">{{cite journal |vauthors=Bajetta E, Di Bartolomeo M, Stani SC, Artale S, Ricci SB, Bozzetti F, Mazzaferro V, Toffolatti L, Buzzoni R |title=Chemoradiotherapy as preoperative treatment in locally advanced unresectable pancreatic cancer patients: results of a feasibility study |journal=Int. J. Radiat. Oncol. Biol. Phys. |volume=45 |issue=2 |pages=285–9 |year=1999 |pmid=10487547 |doi= |url=}}</ref><ref name="pmid25599322">{{cite journal |vauthors=Ferrone CR, Marchegiani G, Hong TS, Ryan DP, Deshpande V, McDonnell EI, Sabbatino F, Santos DD, Allen JN, Blaszkowsky LS, Clark JW, Faris JE, Goyal L, Kwak EL, Murphy JE, Ting DT, Wo JY, Zhu AX, Warshaw AL, Lillemoe KD, Fernández-del Castillo C |title=Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer |journal=Ann. Surg. |volume=261 |issue=1 |pages=12–7 |year=2015 |pmid=25599322 |pmc=4349683 |doi=10.1097/SLA.0000000000000867 |url=}}</ref><ref name="pmid28105634">{{cite journal |vauthors=Xia BT, Fu B, Wang J, Kim Y, Ahmad SA, Dhar VK, Levinsky NC, Hanseman DJ, Habib DA, Wilson GC, Smith M, Olowokure OO, Kharofa J, Al Humaidi AH, Choe KA, Abbott DE, Ahmad SA |title=Does radiologic response correlate to pathologic response in patients undergoing neoadjuvant therapy for borderline resectable pancreatic malignancy? |journal=J Surg Oncol |volume=115 |issue=4 |pages=376–383 |year=2017 |pmid=28105634 |doi=10.1002/jso.24538 |url=}}</ref>
| |
| Toxic effects of chemotherapy can be tolerated more easily before surgery as compared to after resection
| |
| Shrinkage of tumor with neoadjuvant therapy makes resection easier and improves patient prognosis
| |
| Systemic treatment for cancer involving various systems improves prognosis
| |
| No therapy is considered as first line therapy under this category.Decisions for treatment are made on an individual basis.
| |
|
| |
|
| SURGERY
| | == |
| There are different surgical techniques that may be used for resectable pancreatic cancer and their prognosis has been extensively studied: <ref name="pmid12972517">{{cite journal |vauthors=Krzyzanowska MK, Weeks JC, Earle CC |title=Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness |journal=J. Clin. Oncol. |volume=21 |issue=18 |pages=3409–14 |year=2003 |pmid=12972517 |doi=10.1200/JCO.2003.03.007 |url=}}</ref><ref name="pmid16955382">{{cite journal |vauthors=Massucco P, Capussotti L, Magnino A, Sperti E, Gatti M, Muratore A, Sgotto E, Gabriele P, Aglietta M |title=Pancreatic resections after chemoradiotherapy for locally advanced ductal adenocarcinoma: analysis of perioperative outcome and survival |journal=Ann. Surg. Oncol. |volume=13 |issue=9 |pages=1201–8 |year=2006 |pmid=16955382 |doi=10.1245/s10434-006-9032-x |url=}}</ref><ref name="pmid12576921">{{cite journal |vauthors=Aristu J, Cañón R, Pardo F, Martínez-Monge R, Martin-Algarra S, Manuel Ordoñez J, Villafranca E, Moreno M, Cambeiro M, Azinovic I |title=Surgical resection after preoperative chemoradiotherapy benefits selected patients with unresectable pancreatic cancer |journal=Am. J. Clin. Oncol. |volume=26 |issue=1 |pages=30–6 |year=2003 |pmid=12576921 |doi= |url=}}</ref><ref name="pmid19576722">{{cite journal |vauthors=Turrini O, Viret F, Moureau-Zabotto L, Guiramand J, Moutardier V, Lelong B, Giovannini M, Delpero JR |title=Neoadjuvant chemoradiation and pancreaticoduodenectomy for initially locally advanced head pancreatic adenocarcinoma |journal=Eur J Surg Oncol |volume=35 |issue=12 |pages=1306–11 |year=2009 |pmid=19576722 |doi=10.1016/j.ejso.2009.06.005 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid25207767">{{cite journal |vauthors=Ryan DP, Hong TS, Bardeesy N |title=Pancreatic adenocarcinoma |journal=N. Engl. J. Med. |volume=371 |issue=11 |pages=1039–49 |year=2014 |pmid=25207767 |doi=10.1056/NEJMra1404198 |url=}}</ref><ref name="pmid28398845">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MHG |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update |journal=J. Clin. Oncol. |volume=35 |issue=20 |pages=2324–2328 |year=2017 |pmid=28398845 |doi=10.1200/JCO.2017.72.4948 |url=}}</ref><ref name="pmid22569924">{{cite journal |vauthors=Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA |title='Artery-first' approaches to pancreatoduodenectomy |journal=Br J Surg |volume=99 |issue=8 |pages=1027–35 |year=2012 |pmid=22569924 |doi=10.1002/bjs.8763 |url=}}</ref><ref name="pmid24578248">{{cite journal |vauthors=Gurusamy KS, Kumar S, Davidson BR, Fusai G |title=Resection versus other treatments for locally advanced pancreatic cancer |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD010244 |year=2014 |pmid=24578248 |doi=10.1002/14651858.CD010244.pub2 |url=}}</ref><ref name="pmid18958561">{{cite journal |vauthors=Doi R, Imamura M, Hosotani R, Imaizumi T, Hatori T, Takasaki K, Funakoshi A, Wakasugi H, Asano T, Hishinuma S, Ogata Y, Sunamura M, Yamaguchi K, Tanaka M, Takao S, Aikou T, Hirata K, Maguchi H, Aiura K, Aoki T, Kakita A, Sasaki M, Ozaki M, Matsusue S, Higashide S, Noda H, Ikeda S, Maetani S, Yoshida S |title=Surgery versus radiochemotherapy for resectable locally invasive pancreatic cancer: final results of a randomized multi-institutional trial |journal=Surg. Today |volume=38 |issue=11 |pages=1021–8 |year=2008 |pmid=18958561 |doi=10.1007/s00595-007-3745-8 |url=}}</ref><ref name="pmid15086174">{{cite journal |vauthors=Lygidakis NJ, Singh G, Bardaxoglou E, Dedemadi G, Sgourakis G, Nestoridis J, Malliotakis A, Pedonomou M, Solomou EK, Safioleas M, Alamani M, Grigorakos L, Merikas EM |title=Mono-bloc total spleno-pancreaticoduodenectomy for pancreatic head carcinoma with portal-mesenteric venous invasion. A prospective randomized study |journal=Hepatogastroenterology |volume=51 |issue=56 |pages=427–33 |year=2004 |pmid=15086174 |doi= |url=}}</ref><ref name="pmid23532000">{{cite journal |vauthors=Yamada S, Fujii T, Sugimoto H, Nomoto S, Takeda S, Kodera Y, Nakao A |title=Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines |journal=Pancreas |volume=42 |issue=6 |pages=1004–10 |year=2013 |pmid=23532000 |doi=10.1097/MPA.0b013e31827b2d7c |url=}}</ref>
| |
| Pancreaticoduodenectomy (Whipple Procedure)<ref name="pmid26314780">{{cite journal |vauthors=Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, Seufferlein T, Haustermans K, Van Laethem JL, Conroy T, Arnold D |title=Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=26 Suppl 5 |issue= |pages=v56–68 |year=2015 |pmid=26314780 |doi=10.1093/annonc/mdv295 |url=}}</ref><ref name="pmid27247221">{{cite journal |vauthors=Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH |title=Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline |journal=J. Clin. Oncol. |volume=34 |issue=21 |pages=2541–56 |year=2016 |pmid=27247221 |doi=10.1200/JCO.2016.67.5553 |url=}}</ref><ref name="pmid19387741">{{cite journal |vauthors=Evans DB, Farnell MB, Lillemoe KD, Vollmer C, Strasberg SM, Schulick RD |title=Surgical treatment of resectable and borderline resectable pancreas cancer: expert consensus statement |journal=Ann. Surg. Oncol. |volume=16 |issue=7 |pages=1736–44 |year=2009 |pmid=19387741 |doi=10.1245/s10434-009-0416-6 |url=}}</ref>
| |
| It is mainly performed for tumors located in:
| |
| Periampullary region
| |
| Duodenum
| |
| Bile duct (Cholangiocarcinoma)
| |
| Pancreatic duct
| |
| Head of pancreas
| |
| Whipple procedure involves removal of the following components due to common blood supply:
| |
| Stomach antrum
| |
| Gallbladder
| |
| Duodenum
| |
| Head of pancreas
| |
| After removal of the above structures, the biliary and distal pancreatic ducts are anastomosed to the jejunum to facilitate surgical drainage. Biliary drainage may also be performed preoperatively.<ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref><ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref>
| |
|
| |
|
| This procedure is associated with several morbidities:<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid17462460">{{cite journal |vauthors=Pawlik TM, Gleisner AL, Cameron JL, Winter JM, Assumpcao L, Lillemoe KD, Wolfgang C, Hruban RH, Schulick RD, Yeo CJ, Choti MA |title=Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer |journal=Surgery |volume=141 |issue=5 |pages=610–8 |year=2007 |pmid=17462460 |doi=10.1016/j.surg.2006.12.013 |url=}}</ref><ref name="pmid17786531">{{cite journal |vauthors=House MG, Gönen M, Jarnagin WR, D'Angelica M, DeMatteo RP, Fong Y, Brennan MF, Allen PJ |title=Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer |journal=J. Gastrointest. Surg. |volume=11 |issue=11 |pages=1549–55 |year=2007 |pmid=17786531 |doi=10.1007/s11605-007-0243-7 |url=}}</ref><ref name="pmid17592291">{{cite journal |vauthors=Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH, Hwang R, Vauthey JN, Abdalla EK, Lee JE, Pisters PW, Evans DB |title=Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma |journal=Ann. Surg. |volume=246 |issue=1 |pages=52–60 |year=2007 |pmid=17592291 |pmc=1899216 |doi=10.1097/01.sla.0000259391.84304.2b |url=}}</ref>
| | ==Overview== |
| Postoperative abcess
| |
| Wound infection<ref name="pmid17723881">{{cite journal |vauthors=Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib NA, Williamson RC, Jiao LR |title=Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery |journal=Surgery |volume=142 |issue=3 |pages=313–8 |year=2007 |pmid=17723881 |doi=10.1016/j.surg.2007.04.022 |url=}}</ref>
| |
| Anastomotic leak
| |
| Delay in gastric emptying<ref name="pmid17981197">{{cite journal |vauthors=Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW |title=Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS) |journal=Surgery |volume=142 |issue=5 |pages=761–8 |year=2007 |pmid=17981197 |doi=10.1016/j.surg.2007.05.005 |url=}}</ref>
| |
|
| |
| Pylorus sparing Whipple procedure:
| |
| The pylorus may be spared as a modification of Whipple procedure to decrease gastric emptying due to antrectomy. This significantly reduces the incidence of nutritional deficiencies arising from this surgery.
| |
|
| |
|
| | ==References== |
| | {{reflist|2}} |
|
| |
|
| The European Society for Medical Oncology states that the only curative therapy is surgical resection.
| | {{WH}} |
| Ten percent is the five year survival of patients with pancreatic cancer.
| | {{WS}} |
| Patients with node-positive tumors have very poor long term survival.
| |
|
| |
|
| Distal Pancreatectomy <ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref>
| | ===Pathophysiology prev=== |
| This procedure has a limited use in curative resection of pancreatic cancer.
| | <div style="-webkit-user-select: none;"> |
| It is mainly performed for tumors located in:
| | {| class="infobox" style="position: fixed; top: 65%; right: 10px; margin: 0 0 0 0; border: 0; float: right;" |
| Body of pancreas
| | |- |
| Tail of pancreas
| | | {{#ev:youtube|https://https://www.youtube.com/watch?v=5szNmKtyBW4|350}} |
| This form of surgery has fewer morbidities than the Whipple procedure.
| | |- |
| | |} |
| | __NOTOC__ |
| | {{Cirrhosis}} |
| | {{CMG}} {{AE}} |
|
| |
|
|
| | ==Video codes== |
| Distal Pancreatectomy involves the following components:
| |
| Separation of the distal pancreas bearing the tumor from the normal tissue
| |
| Resection of the affected portion
| |
| Oversewing of the distal pancreatic duct
| |
|
| |
|
| This procedure is associated with several morbidities:<ref name="pmid28406793">{{cite journal |vauthors=Elliott IA, Epelboym I, Winner M, Allendorf JD, Haigh PI |title=Population-Level Incidence and Predictors of Surgically Induced Diabetes and Exocrine Insufficiency after Partial Pancreatic Resection |journal=Perm J |volume=21 |issue= |pages= |year=2017 |pmid=28406793 |pmc=5391783 |doi=10.7812/TPP/16-095 |url=}}</ref><ref name="pmid28347869">{{cite journal |vauthors=Liu A, Carmichael KA, Schallom ME, Klinkenberg WD |title=Retrospective review of postoperative glycemic control in patients after distal pancreatectomy |journal=Int J Surg |volume=41 |issue= |pages=86–90 |year=2017 |pmid=28347869 |doi=10.1016/j.ijsu.2017.03.060 |url=}}</ref><ref name="pmid28272344">{{cite journal |vauthors=Gilliland TM, Villafane-Ferriol N, Shah KP, Shah RM, Tran Cao HS, Massarweh NN, Silberfein EJ, Choi EA, Hsu C, McElhany AL, Barakat O, Fisher W, Van Buren G |title=Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection |journal=Nutrients |volume=9 |issue=3 |pages= |year=2017 |pmid=28272344 |pmc=5372906 |doi=10.3390/nu9030243 |url=}}</ref><ref name="pmid27763684">{{cite journal |vauthors=Strobel O, Brangs S, Hinz U, Pausch T, Hüttner FJ, Diener MK, Schneider L, Hackert T, Büchler MW |title=Incidence, risk factors and clinical implications of chyle leak after pancreatic surgery |journal=Br J Surg |volume=104 |issue=1 |pages=108–117 |year=2017 |pmid=27763684 |doi=10.1002/bjs.10316 |url=}}</ref>
| | ===Normal video=== |
| Pancreatic endocrine insufficiency
| | {{#ev:youtube|x6e9Pk6inYI}} |
| Bleeding
| | {{#ev:youtube|4uSSvD1BAHg}} |
| Leakage of pancreatic stump
| | {{#ev:youtube|PQXb5D-5UZw}} |
| | {{#ev:youtube|UVJYQlUm2A8}} |
|
| |
|
| Total Pancreatectomy<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid18043098">{{cite journal |vauthors=Müller MW, Friess H, Kleeff J, Dahmen R, Wagner M, Hinz U, Breisch-Girbig D, Ceyhan GO, Büchler MW |title=Is there still a role for total pancreatectomy? |journal=Ann. Surg. |volume=246 |issue=6 |pages=966–74; discussion 974–5 |year=2007 |pmid=18043098 |doi=10.1097/SLA.0b013e31815c2ca3 |url=}}</ref>
| | ===Video in table=== |
| | <div style="width:350px">{{#ev:youtube|5ucSlgqGAno}}</div> |
|
| |
|
| | ===Floating video=== |
|
| |
|
| It is the least preferred due to high mortality rate.
| | {| class="infobox mw-collapsible" id="floatvideo" style="position: fixed; top: 65%; width:361px; right: 10px; margin: 0 0 0 0; border: 0; float: right;" |
| It is mainly performed for tumors located in:
| | | Title |
| Neck of the pancreas.
| | |- |
| Due to involvement of neck, patients develop insulin dependent DM.
| | |- |
| | | {{#ev:youtube|https://https://www.youtube.com/watch?v=ypYI_lmLD7g|350}} |
| | |- |
| | |} |
|
| |
|
| CA 19-9 level
| | ===Redirect=== |
| | #REDIRECT[[Esophageal web]] |
|
| |
|
| Elevated levels of CA 19-9 can help in the following ways:<ref name="pmid27049786">{{cite journal |vauthors=Bergquist JR, Puig CA, Shubert CR, Groeschl RT, Habermann EB, Kendrick ML, Nagorney DM, Smoot RL, Farnell MB, Truty MJ |title=Carbohydrate Antigen 19-9 Elevation in Anatomically Resectable, Early Stage Pancreatic Cancer Is Independently Associated with Decreased Overall Survival and an Indication for Neoadjuvant Therapy: A National Cancer Database Study |journal=J. Am. Coll. Surg. |volume=223 |issue=1 |pages=52–65 |year=2016 |pmid=27049786 |doi=10.1016/j.jamcollsurg.2016.02.009 |url=}}</ref>
| | ===synonym website=== |
| | https://mq.b2i.sg/snow-owl/#!terminology/snomed/10743008 |
|
| |
|
| Predicts the likelihood of complete resection
| | ===Image=== |
| | [[Image: Normal versus Abnormal Barium study of esophagus.jpg|thumb|left|200px|Normal versus Abnormal Barium study of esophagus with varices]] |
|
| |
|
| Prognosis of patients with resectable disease
| |
|
| |
|
| Predicts the presence of occult metastases
| | ===Image to the right=== |
| | {| style="float: right; width: 350px;" |
| | | [[Image:Coxiella burnetii.JPG|right|400px|C. burnetii, the Q fever causing agent]] |
| | |} |
|
| |
|
| However, CA 19-9 levels are not used to dictate the initial strategy for treatment of pancreatic cancer.
| | ===Image and text to the right=== |
|
| |
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| PALLIATIVE THERAPY
| | <figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline><figure-inline>[[File:Global distribution of leptospirosis.jpg|577x577px]]</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline> Recent out break of leptospirosis is reported in Bronx, New York and found 3 cases in the months January and February, 2017. |
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| Pain
| | ===Gallery=== |
| There are various techniques for pain management as palliative therapy in patients:
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| Narcotic analgesics
| | <gallery widths="250px"> |
| Narcotic analgesics+ tricyclic antidepressants/ antiemetics
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| Endoscopic decompression with stent placement in patients with biliary or pancreatic duct obstruction
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| Radiation therapy
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| Neurolysis of the celiac ganglia by many approaches
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| Intraoperative
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| Transgastric
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| Transthoracic
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| Transabdominal
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| Jaundice
| | Pancreatic insulinoma histology 2.JPG|Histopathology of a pancreatic endocrine tumor (insulinoma). ''Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas''<ref name=aaa> Neuroendocrine tumor of the pancreas. Libre Pathology. http://librepathology.org/wiki/index.php/Neuroendocrine_tumour_of_the_pancreas</ref> |
| Obstructive jaundice can present with features of cholangitis:
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| Fever and chills
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| Nausea, vomiting
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| Clay-colored stools
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| Dark urine
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| Yellowish discoloration of skin
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| Pruritus
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| Right upper quadrant pain
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| Anorexia
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| Preferred treatment in patients: Endoscopic decompression with stent placement in patients with biliary obstruction
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| Techniques of biliary decompression:
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| Cholecystojejunostomy
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| Choledochojejunostomy
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| Types of stents:
| | Pancreatic insulinoma histopathology 3.JPG|Histopathology of a pancreatic endocrine tumor (insulinoma). Chromogranin A immunostain. ''Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas''<ref name=aaa> Neuroendocrine tumour of the pancreas. Libre Pathology. http://librepathology.org/wiki/index.php/Neuroendocrine_tumour_of_the_pancreas</ref> |
| Metal- costly, longer lifespan
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| Plastic- cheaper, need replacement every three months
| | Pancreatic insulinoma histology 4.JPG|Histopathology of a pancreatic endocrine tumor (insulinoma). Insulin immunostain. ''Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas''<ref name=aaa> Neuroendocrine tumour of the pancreas. Libre Pathology. http://librepathology.org/wiki/index.php/Neuroendocrine_tumour_of_the_pancreas</ref> |
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| Duodenal obstruction
| | </gallery> |
| Preferred treatment:
| | ==References== |
| Endoscopic stenting of duodenal obstruction
| | {{Reflist|2}} |
| Gastrojejunostomy
| | {{WS}} |
| | {{WH}} |
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| | |
| | REFERENCES |
| <references /> | | <references /> |
| | |
| | [[Category:Gastroenterology]] |
| | [[Category:Needs overview]] |
| | [[Category:Hepatology]] |
| | [[Category:Disease]] |
</figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline></figure-inline> Recent out break of leptospirosis is reported in Bronx, New York and found 3 cases in the months January and February, 2017.
![Histopathology of a pancreatic endocrine tumor (insulinoma). Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas[1]](/images/2/2f/Pancreatic_insulinoma_histology_2.JPG)
Histopathology of a pancreatic endocrine tumor (insulinoma). Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas[1]![Histopathology of a pancreatic endocrine tumor (insulinoma). Chromogranin A immunostain. Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas[1]](/images/a/a3/Pancreatic_insulinoma_histopathology_3.JPG)
Histopathology of a pancreatic endocrine tumor (insulinoma). Chromogranin A immunostain. Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas[1]![Histopathology of a pancreatic endocrine tumor (insulinoma). Insulin immunostain. Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas[1]](/images/d/d5/Pancreatic_insulinoma_histology_4.JPG)
Histopathology of a pancreatic endocrine tumor (insulinoma). Insulin immunostain. Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas[1]![Histopathology of a pancreatic endocrine tumor (insulinoma). Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas[1]](/index.php/File:Pancreatic_insulinoma_histology_2.JPG)
![Histopathology of a pancreatic endocrine tumor (insulinoma). Chromogranin A immunostain. Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas[1]](/index.php/File:Pancreatic_insulinoma_histopathology_3.JPG)
![Histopathology of a pancreatic endocrine tumor (insulinoma). Insulin immunostain. Source:https://librepathology.org/wiki/Neuroendocrine_tumour_of_the_pancreas[1]](/index.php/File:Pancreatic_insulinoma_histology_4.JPG)