Pancreatic Cancer

1. Pancreatic Cancer Marco Bruno & Lars Lundell

2. Pancreatic Cancer Case Case presentation • 67 year old male • Unremarkable previous medical history • No family history of pancreatic cancer or other tumour syndromes • Heavy smokers (>15 per day for more than 40 year) • Obstructive jaundice, bili 378 • CT: mass lesion in pancreatic head. No signs of vascular involvement or metastases

3. Pancreatic Cancer Case Question 1 Whatwouldyou do? • send patient direct for Whipple’s surgery • before considering surgery first do ERCP to image stricture en drain the biliary tree

4. Pancreatic Cancer Case Question 1 Direct surgery is not inferior to PBD1 • rate of surgical complications are is not lowered after PBD • high rate of stent related complications • PDB adds substantially to the overall costs 1N Engl J Med. 2010 Jan 14;362(2):129-37

5. Pancreatic Cancer Case Question 2 Wouldyouconsider EUS? • yes, to confirm the presence of the lesion and non involvement of the vessels • yes, to confirm diagnosis by means of fine needle aspiration • no, has no added value to CT scan

6. Pancreatic Cancer Case Question 2; background information • Series dealing with imaging are largely retrospective or small cohort series • Importantly, most studies are already dated and do no justice to CT and MR advancements in recent years • EUS is probably still the most sensitive modality tot detect small lesions (< 2 cm) • Differential diagnosis? Elastography? Contrast-enhanced?

7. Pancreatic Cancer Case Question 3 If CT shows a relationshipwith the portal vein. Wouldyoustillconsidersurgery? • always surgery with vascular resection and portal vein reconstruction unless full circumferential involvement and narrowing • depends on the extent of involvement • do EUS to confirm involvement and then deny resection • surgery is not indicated; palliative treatment

8. Pancreatic Cancer Case Question 3 • Systematic review of 28 retrospective studies (1458 patients) • Vein thrombosis or arterial involvement reported as contraindications to surgery in 62% and 71% of studies • Median mortality rate 4% (0 to 17%) • Median R0 and R1 rates were 75% (14% to 100%) and 25% (0% to 86%) 1 J GastrointestSurg. 2010 : ahead of publ.

9. Pancreatic Cancer Case Question 3 • Nine of 10 (90%) studies comparing survival after extended pancreaticoduodenectomy with vascular resection versus standard pancreaticoduodenectomy reported statistically similar (p > 0.05) survival outcomes • Overall, vascular resection was not associated with a poorer survival. 1 J GastrointestSurg. 2010 : ahead of publ.

10. Pancreatic Cancer Case Question 4 Ifitturns out that the tumourcannotberesectedradically at exploration, whatwouldyou do? • still resect the tumour; this is the best palliation • perform a gastrojejunostomy and hepaticojejunostomy • Only perform a gastrojejunotomy • Close the abdomen and deal with biliary and gastric outlet obstruction endoscopically

11. Pancreatic Cancer Case Question 4 • Systematic review and meta-analysis of prophylactic gastrostomy for unresectable cancer • 3 prospective comparative studies • chance of gastric outlet obstruction during follow-up was significantly lower (OR 0.06, 95% CI 0.02 to 0.21) • No increased morbidity of mortatlity at the expense of 3 days longer hospital admission • No such data available for prophylactic biliary bypass surgery Br J Surg 2009: 96; 711-9

12. Pancreatic Cancer Case Question 4 • In case of symptomatic gastric outlet obstruction in palliative patients there very few prospective and/or randomized data • Small randomized trial 19 patients GJJ and 21 stent placement1 • more rapid improvement of food intake after stent • more re-interventions after stent • long-term relief better after GJJ (GOOSS score > or = 2, 72 days versus 50 days) • Recommendation: Stent if suspected survival is less then 2 months 1GastrointestEndosc 2010 : 71; 490-499

13. Pancreatic Cancer Case Question 5 How do you deal with a malignant biliary obstruction in unresectablepancreaticcancer? • Always place a plastic stent • Always place a metal stent • Metal only in case of fast occlusion of plastic stent or expected long survival • Surgical bypass in cases with expected long survival

14. Pancreatic Cancer Case Question 5 • Answer largely depends on which perspective one chooses • Patency rates of metal stents are undoubtedly superior to plastic stents • From a cost perspective POV the use of metal stents is depended on • patient survival (>3 months(?)) • unit cost of additional ERCP at institution (>$1820)1 • Preventing cholangitic complication may prove to be of more importance if palliative chemotherapy is given at a higher rate to patients 1Eur J Gastroenterol 2007: 19; 1041-2

15. Pancreatic Cancer Case Question 6 Do you offer patientswithunresectablepancreaticcancer (palliative) chemotherapy? • No, there is no scientific proof for its efficacy • No, it may increase QoL to some extent, but to me this doe not justifies its use • Yes, there is enough scientific proof of efficacy to justify its routine use

16. Pancreatic Cancer Case Question 6 • Two high quality systematic reviews comparing best supportive care to chemotherapy in advanced pancreatic cancer. • Overall survival was significantly better • One-year mortality was significantly reduced • However, unfit patients with a poor Karnosfsky status (<70%) have only marginal benefit from chemotherapy and may often benefit more from optimal supportive care J ClinOncol 2007: 25; 2607-15 Cochrane Database SystRev 2006:3 World J Gastroenterol 2007: 13; 224-7