Treatment Of Pancreatic Cancer
Pancreatic cancer requires multidisciplinary treatment and requires surgery, chemotherapy, and radiation, alone or in combination.
Surgical management
Surgical treatment is considered the best way to cure pancreatic cancer as it can significantly prolong survival. The surgical procedures include:
1. Pancreatectomy
It consists of the Whipple procedure (pancreaticoduodenectomy), which is an operation to remove the head of the pancreas. Along with this, the distal or total pancreatectomy (removal of the pancreas) is the best surgical option for the resection of pancreatic cancer depending on the anatomical location of the tumor or tumors. It requires:
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Preoperative biliary drainage: A significant proportion of patients with pancreatic cancer present with jaundice and pre-operative drainage relieves the obstruction and may reverse the pathophysiological dysfunction caused by obstructive jaundice.
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Anastomotic technique: A major source of death following Whipple’s procedure is a leak from pancreatic anastomosis and the formation of a pancreatic fistula. It consists of anastomosing (suturing) the pancreatic duct to the jejunum (middle part of the small intestine) or stomach.
2. Laparoscopic surgery
Laparoscopy is a type of surgical procedure that allows a surgeon to access the inside of the abdomen (tummy) and pelvis without having to make large incisions in the skin. This minimally invasive surgery requires laparoscopic distal pancreatectomy for the resection. There was no difference in the rate of positive resection margins and outcomes.
3. Vascular resection
The relationship between any pancreatic tumor and the surrounding vasculature is an important determinant of how much resection needs to be done. Pancreatic cancer resection includes total pancreatectomy, distal pancreatectomy plus splenectomy (removal of the spleen).
Medical management
1. Adjuvant chemotherapy
Chemotherapy is an important part of the comprehensive treatment of pancreatic cancer. The overall survival rate after radical resection and adjuvant chemotherapy improves in most cases. Generally, used chemotherapy regimens after radical resection are:
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Modified leucovorin, 5-fluorouracil, irinotecan, and oxaliplatin (MFOLFIRINOX) for 6 months
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Gemcitabine and capecitabine combined for 6 months
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Folfirinox regimen, gemcitabine, and Pac-Nab in combination with chemotherapy in patients with metastasis (spread of cancer to other organs)
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Gemcitabine is the first choice if the patient is not suitable for combination chemotherapy
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Gemcitabine (with or without erlotinib) combined with 54 Gy (radiation dose) is used for patients with locally advanced pancreatic cancer
2. Neoadjuvant treatment
It is treatment given as a first step to shrink a tumor before the main treatment, which is usually surgery since a relapse of symptoms is usually seen in 71% and 76% percent of patients within two years. Furthermore, due to complications associated with surgery up to 40% of patients are not suitable for progression to adjuvant therapy. A good success rate with neoadjuvant treatment in several other cancers including rectal, oesophageal, and gastric cancer have led to the exploration of the impact of neoadjuvant treatment in pancreatic cancer as well.
Radiotherapy
Radiation therapy uses X-rays to destroy or damage cancer cells, making them unable to proliferate. Radiotherapy is mainly used in patients with locally advanced pancreatic cancer. It uses:
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External beam radiation therapy: This uses external radiation therapy sources that emit X-rays, gamma rays, electrons or heavy particles.
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Brachytherapy: It is a type of internal radiation therapy in which seeds, ribbons, or capsules that contain a radiation source are placed inside the body, or near the tumors. It is mainly used for internal radiotherapy by surgery or laparoscopy in the pancreas or adjacent to the pancreas.
Targeted therapy
This is very successful in many types of cancer, though, to date, all other targeted drugs have failed in pancreatic cancer patients, including affrecept, cetuximab, sorafenib, bevacizumab, and axitinib. Recently the Food and Drug Administration (FDA) has approved pembrolizumab as a targeted treatment for pancreatic cancer.
Latest treatment protocols
A lot of research and studies on the latest treatment options are going on. Some of them are:
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Gene therapy: Gene therapy is the delivery of specific genes to cancer cells, which are often carried by specially designed viruses.
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Cancer stem cells: Research is currently focused on identifying treatments that may specifically target the pancreatic cancer stem cells.
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Genetic/molecular studies: Many new research developments are based on identifying damaged genes and proteins and repairing them or changing how they work.
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Circulating tumor (ct)DNA: The ctDNA is being studied as a tool for monitoring response to treatment, for observing early signs of disease recurrence, and as a way to determine the disease's resistance to the ongoing treatment.
Other treatment modalities
Patients with pancreatic cancer need palliative care at some point, it is as important as other treatments themselves. Some of the procedures done for the management of patients with gastric outlet obstruction include:
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Percutaneous bile duct drainage: A procedure to drain bile to relieve pressure in the bile ducts caused by a blockage.
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Surgical gastrojejunostomy: A surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum.
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Endoscopic duodenal stents: A stent is a small metal mesh tube that is placed in the narrowed or blocked area of your duodenum (first part of the small intestine).