Pancreatic cancer: the bigger picture.

Despite accurate diagnosis, better radiologic techniques, and safer surgery, long-term survival after surgical therapy for pancreatic cancer is disappointing. Median survival following pancreaticoduodenal resection is 12 to 15 months independent of surgical expertise, hospital size, or technical factors. Subsets of favorable tumors and longer survival times after surgery have been defined and include: small tumor size and low-grade lesions, tumor-free margins, and absence of nodal, venous, or perineural invasion; however, long-term survivors of pancreatic cancer may have none of these favorable features, and their tumors commonly manifest the most adverse tumor prognostic features. The converse that small-sized, histologically favorable tumors result in long-term survivors, also is not true. Five-year survival rates average 5% or less after all resections. In a large series in which 118 pancreatic resections were performed in 684 evaluated patients over a 6-year period, there were 12 5-year survivors, 5 of whom died in the sixth year. A report of 10-year survivors after surgery numbered 13 patients. The best actual 5-year survival rate was reported by Trede et al. Of the 37, 5-year survivors from a cohort of 118 patients, more than half died of cancer. This far exceeds any other actual survival rate and may be explained by a smaller tumor size. Farnell et al reported a 5-year survival rate difference (i.e., actuarial survival) in a subset of 174 resected patients with adenocarcinoma without perineural or duodenal invasion and with negative nodes (23% versus 6.8%), respectively. An impressive, large series of 616 patients with resected adenocarcinoma of the pancreas who underwent PDR (85%), distal pancreatectomy (9%), and total pancreatectomy (6%), has been reported. The mortality rate was 2.1%, and postoperative complications occurred in 30%. The five-year survival rate was 15%. The author's best result was observed among 20 initially "unresectable" patients who were treated with chemoradiation therapy, followed by tumor extirpation. Among the 18 surgical survivors there are seven five-year survivors, three of whom are in their tenth year of survival. They are discussed in the article by Cooperman et al ("Long-term Follow-up...") elsewhere in this issue.     

Pancreatic cancer: Slow progression in the early stages

INTRODUCTIONThe rates of pancreatic cancer development in the early stages of growth remain unclear; but it is generally believed that they demonstrate a rapid degree of progression. There is evidence to suggest that pancreatic cancers measuring less than 1 cm demonstrate better survival rates, hence it is clear that detecting pancreatic cancers less than 1 cm in size is of paramount importance. However, to date, there has been no scientifically adequate research to show the growth rate of small pancreatic cancers less than 1 cm in the early stages.PRESENTATION OF CASEWe present the case of a 65-year-old woman whose small pancreatic cancer possibly demonstrated a slow progressive rate as it grew to an invasive carcinoma measuring 1 cm diameter from over the 29 months.DISCUSSIONIt is reasonable to assume that the progression of some pancreatic cancers until 1 cm size, can take up to 29 months. During this silent period, it is crucial to detect such a small pancreatic cancer by means of the initial US and subsequent EUS and ERCP. It is clear, therefore, that clinicians have to be aware of the growth rate of small pancreatic cancers and in particular high risk patients should be encouraged to monitor size of the main pancreatic duct by means of US on regular basis.CONCLUSIONThis could give better outcomes for pancreatic cancer patients. Hopefully, by detecting these lethal, pancreatic cancers in their early stages, it will give us an extension of time to perform effective therapies.     

Pancreatic cancer

During 1972-1981, a total of 177 individuals were diagnosed as having pancreatic cancer at the Central Hospital of Eskilstuna, Sweden. The mean crude incidence rate was 15.0 X 10(-5) year-1. Only 56% of the patients had the diagnosis made prior to death. 63% of the cancers had advanced beyond therapeutic range. Symptoms compatible with upper abdominal disease for more than six months prior to diagnosis occurred in 27% of the cases, and 15% had sought medical advice more than 6 months prior to diagnosis. Radical surgery was performed on 5 patients of whom one died postoperatively, and 61 patients (34%) underwent palliative treatment. The postoperative mortality rate after palliative treatment was 28%. The mean survival time for the whole series was 2.6 months, and 13% survived for one year. One patient survived for 2 years after palliative treatment. It is concluded that the only means by which the prognosis for patients with pancreatic cancer may be improved is to define populations at high risk and to develop more specific and sensitive diagnostic methods.     

Pancreatic cancer

Pancreatic cancer remains a devastating diagnosis whose prognosis has remained largely unchanged over the last two decades. Where possible, surgical resection represents the optimal treatment strategy, yet just one-fifth of patients meet the operative criteria. The non-specific nature of presentation coupled with its relative chemoresistance are partly responsible for the poor survival rates. Improvements in understanding the natural history of the disease, more sophisticated imaging techniques and increased use of endoscopic ultrasound, has allowed earlier detection and expeditious management of pancreatic cancer. The use of FOLFIRINOX and gemcitabine nab-paclitaxel regimens has shown improved median survival in patients with widespread metastatic disease. To this end, these regimens have been used with some success in the neoadjuvant setting. Future perspectives include studying the carcinogenesis of pancreatic malignancy and tumour related genetic mutations, which it is hoped will lead to new developments in the management of pancreatic cancer, and in turn improved survival rates.     

Pancreatic cancer

Improving the survival of patients with pancreatic ductal adenocarcinoma (PDAC) remains an oncological and surgical challenge. The non-specific nature of presenting symptoms results in approximately 50% of patients having advanced disease at diagnosis, coupled with its relative chemoresistance result in persistently poor survival rates. Unfortunately, even long-term outcomes following surgical resection for PDAC remains poor, with only 20% of patients surviving 5 years after pancreatectomy. Patient selection for surgery remains sub-optimal largely due to the absence of consideration of aggressive tumour biology. The benefits of FOLFIRINOX for patients with metastatic disease are now being realized in the adjuvant setting and potentially in the neoadjuvant space coupled with improved understanding of the impact of treatment sensitive molecular subgroups. For all patients with PDAC, management should incorporate multidisciplinary management; integrated supportive care with comprehensive germline testing becoming increasingly applied. The future will likely see gradual progression to more patient-centred treatment algorithms based on tumour molecular profiling with the aim of improving not only survival outcomes, but also quality of life.     

Pancreatic cancer

Pancreatic cancer accounts for 3% of all cancers in the UK; 7000 new cases are diagnosed annually and a similar number die from the disease each year. It has an insidious onset and, as a result, presentation is usually late, with only about 10–20% of patients having disease amenable to surgical resection. Following resection, the median survival is 11–20 months and the 5-year survival is 7–25%. Patients with unresectable locally advanced disease have a median survival of 6–11 months, and those with metastatic disease have a median survival of 2–6 months. Accurate staging has a vital role in the management of pancreatic tumours now that non-surgical palliative options are available. Computed tomography is currently the imaging modality of choice for diagnosis and staging of pancreatic cancer. With recent advances in magnetic resonance imaging and endoscopic ultrasonography, it is now possible to improve the accuracy of preoperative staging, particularly with respect to local invasion and regional node involvement. Resection is the only treatment that offers the potential of cure; ideally, an R0 resection should be aimed for. Chemotherapy renders a survival advantage in the adjuvant setting, even in patients undergoing R1 resections. Palliative chemotherapy can improve survival by 10–15% and other palliative therapies are aimed at relieving jaundice, controlling pain, treating malabsorption and reversing cancer cachexia.     

Pancreatic cancer

It is anticipated that by 2030 pancreatic cancer will be the second leading cause of death from cancer. Surgery remains the only potentially curative therapy. However, less than a quarter of patients are suitable for surgical resection. The lack of early symptoms, the propensity for pancreatic cancer cells to metastasize early in disease development together with the marked resistance to chemotherapy and radiotherapy, are partly responsible for the poor survival rates. Recent improvements in diagnostic imaging, such as pancreas protocol computed tomography and the role of endoscopic ultrasound, allow for earlier detection and facilitate earlier management of pancreatic cancer. In recent years, the approved use of FOLFIRINOX and gemcitabine nab-paclitaxel regimens in patients with metastatic disease has seen an improvement in survival rates and there has been increasing interest in its use in neoadjuvant chemotherapy. Future perspectives include studying the carcinogenesis of pancreatic malignancy and tumour-related genetic mutations, which it is hoped will lead to new developments in the management of pancreatic cancer, and indeed in survival rates.     

Pancreatic cancer

Pancreatic cancer accounts for 3% of all cancers in the UK; 7000 new cases are diagnosed annually and a similar number die from the disease each year. It has an insidious onset and as a result presentation is usually late, with only about 10–20% of patients having disease amenable to surgical resection. Following resection, the median survival is 11–20 months and the 5-year survival is 7–25%. Patients with unresectable locally advanced disease have a median survival of 6–11 months, and those with metastatic disease have a median survival of 2–6 months. Accurate staging has a vital role in the management of pancreatic tumours now that non-surgical palliative options are available. Computed tomography is the imaging modality of choice for diagnosis and staging of pancreatic cancer. With recent advances in magnetic resonance imaging and endoscopic ultrasonography, it is now possible to improve the accuracy of preoperative staging, particularly with respect to local invasion and regional node involvement. Resection is the only treatment that offers the potential of cure; ideally, an R0 resection should be aimed for. Chemotherapy renders a survival advantage in the adjuvant setting, even in patients undergoing R1 resections. Palliative chemotherapy with gemcitabine can improve survival by 10–15% and other palliative therapies are aimed at relieving jaundice, controlling pain, treating malabsorption and reversing cancer cachexia.     

Pancreatic cancer: management and survival

AIM: To review the management and survival from all pancreatic cancer over a 5-year period at a tertiary referral hospital in New Zealand and to examine similar outcome data from the national cancer registry. METHODS: A retrospective audit was conducted for the 5-year period 1994-99 of patients discharged from Christchurch Hospital (Christchurch, New Zealand) and all patients in the New Zealand Cancer Registry with a diagnosis of pancreatic cancer. Kaplan- Meier survival curves were used for analysis. RESULTS: From Christchurch Hospital a total of 230 patients were identified with a discharge diagnosis of pancreatic cancer. Medium survival for all groups was 3.9 months. There was a median survival of 1.6 months for the non-interventional group, 3.1 months for the stent group, 6.2 months for the bypass group and 12.6 months for the pancreatico-duodenectomy group. These data are very similar to the New Zealand National Cancer Registry data, where the overall median survival was 3.1 months and median survival for a pancreatico-duodenectomy was 13.9 months. CONCLUSION: A pancreatico-duodenectomy is usually a palliative surgical technique and not a curative procedure. Those selected for resection have been shown to have an advantage over operative bypass in terms of length of survival, however, this most likely reflects selection bias.     

胰腺星形细胞在胰腺癌中的作用

胰腺癌是常见的消化道恶性肿瘤之一,因早期诊断困难,恶性程度高,手术切除率低,并对化放疗均不敏感,故预后极差.其病理特征之一是肿瘤中有大量的结缔组织形成反应.而胰腺星形细胞(PSCs)在这一反应中起重要作用,并通过与胰腺癌细胞的相互作用,对胰腺癌细胞的增生、侵袭和转移有重要作用.本文就PSCs在胰腺癌发展中的作用及机制作一综述.     

Pancreatic cancer: continuing diagnostic and therapeutic dilemma

Improved survival for patients with cancer of the pancreas awaits future therapeutic advances. A more immediate objective for these patients is to provide accurate diagnosis and effective palliation. Adherence to a diagnostic strategy should provide an accurate diagnosis with the least number of tests, minimizing cost to the patient in terms of both money and discomfort. Effective palliation using a variety of available techniques can and should be accomplished expeditiously in order to extend useful survival.     

Pancreatic cancer: surgery alone is not sufficient

For a patient with resected pancreatic cancer at the head of the pancreas, the goal of the medical community in the new millennium is a long-term survival rate exceeding 50% at 5 years. This goal can best be achieved with the following formula: accurate staging by improved imaging that includes laparoscopy for selected patients with locally extensive disease using computed tomography; a balanced resection, not too extensive and not too limited; centralized treatment in high-volume centers, which includes not just the surgeons and hospitals, but also the chemotherapy infusion units; and use of an effective adjuvant or neoadjuvant treatment in which toxicity is associated with efficacy. The ideal outcome for the surgeon is delivery of a patient who has been accurately staged to receive the most appropriate treatment in a timely fashion for an effective chemoradiotherapy protocol. To do this, the surgeon should use objective benchmarks of safe pancreatic resection, which involves resecting only enough, achieving low blood loss, and achieving a minimal length of hospital stay. The outcome is a patient who has optimized his or her gastrointestinal, endocrine, and exocrine functions and is ready for adjuvant treatment 6 weeks after resection. Surgery alone is not sufficient.     

Pancreatic cancer in the general population: Improvements in survival over the last decade

Background: It is unknown whether the improved survival seen at high-volume centers has been translated to all patients with pancreatic cancer. Objective: To use the Surveillance, Epidemiology, and End Results (SEER) database to evaluate population-based trends in surgical resection and survival. Methods: All patients diagnosed with pancreatic cancer from 1988–1999 were identified. The survival and proportion of patients undergoing surgical resection were compared for each of three equal time periods. Results: There were 24,016 patients with pancreatic cancer. 19,533 had stage data available. 9% had localized, 29% had regional, and 62% had distant disease. Resection rates increased for patients with localized and regional disease over the three time periods. Survival increased for patients with regional and distant disease. For regional pancreatic cancer patients, 2-year survival increased from 9.5% to 13.5% (p<0.0001) and from 21.5% to 28.9% following surgical resection (p=0.002). For resected local/regional pancreatic cancer, the year of diagnosis was and independent predictor of improved survival (p=0.0001). Conclusions: SEER patients with regional and distant pancreatic cancer have improved survival over the past decade in both unadjusted and adjusted models. The improvement is most striking for patients with regional disease and reflects increased resection rates and improved resection techniques over time. Presented at the Forty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20–24, 2006 (oral presentation). Work supported in part by the American Cancer Society-Institutional Research Grant, IRG-96-152-07.