Treatment of Pancreatic Cancer

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Treatment of Localised and Locally Advanced Pancreatic Cancer

Treatment of pancreatic cancer depends on the stage, resectability, performance status of the patient, along with other factors. But the final treatment decision is taken by the oncologist after clinical evaluation of the patient. We will first discuss the resectability of the pancreatic tumor, depending upon the extent of tumor.

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Resectability of Pancreatic Tumor

Tumor located within the pancreas, without extension to adjacent structutes, is considered to be resectable. This figure shows a resectable tumor located in the head of pancreas. head of the pancreas tumor Similarly, this is a resectable tumor located in the tail of pancreas. tail of the pancreas tumor A tumor located in the head of the pancreas, that extends to involve the duodenum, is also considered to be resectable. involves duodenum Similarly, tumors arising from the tail of pancreas, that involve the spleen, left kidney, or left suprarenal gland, may also be resected. extends to spleen, left kidney, or left suprarenal gland Superior mesenteric vein involvement maybe considered resectable, boderline resectable or unresectable, depending upon the extent of arterial involvement. involves superior mesenteric vein Similarly, involvement of portal vein maybe considered resectable, borderline resectable or unresectable, depending upon the extent of arterial involvement. involves portal vein Infiltration of tumor into common hepatic artery only, is borderline resectable in most of the cases. t4-invades common hepatic artery Infiltration of tumor into the superior mesentric artery maybe considered borderline resectable or unresectable, depending upon the extent of arterial involvement. T4 stage - pancreatic tumor involves superior mesenteric artery Celiac artery involvement may also be borderline resectable or unresectable, depending upon the extent of arterial involvement. infiltrates celiac artery resectable, borderline resectable and unresectable pancreatic cancer

Treatment of Pancreatic Cancer based on Resectability

Now we will discuss the treatment for all the three, that is resectable, borderline resectable, and unresectable disease.

Resectable

It includes the cases that are localised to pancreas, or infiltrate into duodenum, spleen or left kidney or suprarenal gland. Superior mesenteric vein or portal vein involvement may be resectable only in selected cases.

Surgical Resection is the treatment of choice for resectable disease, with addition of chemotherapy in high-risk cases.

Borderline Resectable

Common hepatic artery involvement by tumor is included in this. Depending on the extent of involvement, invasion of superior mesenteric artery, celiac artery, superior mesenteric vein or portal vein may be considered borderline resectable.

In such cases, chemotherapy with/without radiotherapy is given and then decision for surgery is taken depending on response to treatment.

Unresectable

Depending on the extent of involvement, invasion of superior mesenteric artery, celiac artery, superior mesenteric vein or portal vein may be considered unresectable.

Chemotherapy with/without radiotherapy is the preferred treatment in such cases. pancreatic cancer treatment based on resectability

The final decision is taken by the oncologist, on an individual patient basis, depending upon the performance status of the patient and exact stage of the disease.

Treatment of Metastatic Pancreatic Cancer

It may present as metastasis to peritoneum, in form of multiple peritoneal deposits. metastasis to peritoneum Or metastatis to liver,Lungs. metastatis to liver                                             metastasis to lungs Very rarely, it may also spread to brain or bones. Chemotherapy, immunotherapy and/or targeted therapy is the standard treatment for metastatic disease. Radiation therapy, surgery, or other modalities may be used for palliation or relief of symptoms. pancreatic cancer treatment-metastatic disease

Stagewise Treatment of Pancreatic Cancer

Stage I

T1-2 N0 M0 Tumors are considered resectable Radical pancreatic resection such as Whipple procedure (resection of pancreas and duodenum), or partial pancreatic resection (depending on location, extent of tumor, etc) is considered the preferred treatment approach in case of resectable tumors.

Stage II

T1-3 N0-1 M0 Tumors are considered borderline resectable Chemotherapy with or without radiation therapy is generally employed followed by surgery (if disease become resectable).

Stage III

T4 N0-1 M0 Chemotherapy and/or radiation therapy is generally warranted along with palliative therapy such as surgery (biliary/gastric bypass) or endoscopic biliary stent placement.

Stage IV

Any T Any N M1 Chemotherapy or immunotherapy is the mainstay of treatment in case the disease has spread to distant body parts. Along with the chemotherapy, palliative therapy to relieve pain or stent placement may be employed as and when required.

Role of Surgery

surgery for pancreatic cancer Surgery provides significantly longer survival and is considered as the treatment of choice for resectable pancreatic cancers.

Radical pancreatic resection such as Whipple procedure (resection of pancreas and duodenum), partial, or complete pancreatic resection are some common surgical procedures employed with a curative intent for resectable and borderline resectable pancreatic cancers.

For unresectable pancreatic cancers, surgery is employed for palliation of symptoms, which may include biliary/gastric bypass surgery and biliary stent placement to relieve bile duct blockage.

Chemotherapy for Pancreatic Cancer

Chemotherapy may be used for pancreatic cancer in neoadjuvant setting (before surgery to downsize the tumor and make it resectable), concurrent chemoradiation (used along with radiation therapy), adjuvant treatment (after surgical resection of tumor) or palliative treatment (in case of unresectable or metastatic disease).

Chemotherapeutic agents used for pancreatic cancer treatment are-

Role of Immunotherapy

pembrolizumab Pembrolizumab had been granted US FDA approval for the treatment of MSI-H or dMMR positive unresectable/metastatic pancreatic cancers that have progressed on prior treatment and for which no satisfactory alternative treatment option is available.

Role of Targeted Therapy

targeted therapy for pancreatic cancer Targeted drugs target a specific gene or protein characteristic of the pancreatic cancer cells, for example, erlotinib targets epidermal growth factor receptor (EGFR). They are generally used alone or in combination with chemotherapy for the treatment of advanced disease.

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