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.
- Symptoms and Signs of Pancreatic Cancer
- Stages of Pancreatic Cancer
- Risk Factors for Pancreatic Cancer
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. Similarly, this is a resectable tumor located in the tail of pancreas. A tumor located in the head of the pancreas, that extends to involve the duodenum, is also considered to be resectable. Similarly, tumors arising from the tail of pancreas, that involve the spleen, left kidney, or left suprarenal gland, may also be resected. Superior mesenteric vein involvement maybe considered resectable, boderline resectable or unresectable, depending upon the extent of arterial involvement. Similarly, involvement of portal vein maybe considered resectable, borderline resectable or unresectable, depending upon the extent of arterial involvement. Infiltration of tumor into common hepatic artery only, is borderline resectable in most of the cases. Infiltration of tumor into the superior mesentric artery maybe considered borderline resectable or unresectable, depending upon the extent of arterial involvement. Celiac artery involvement may also be borderline resectable or unresectable, depending upon the extent of arterial involvement.
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.
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.
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.
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.
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. Or metastatis to liver,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.
Stagewise Treatment of Pancreatic Cancer
Stage IT1-2 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 IIT1-3 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 IIIT4 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.
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 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 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 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.