Transcript C03 Lundell (type , size 637 kB)

Pancreatic Cancer
Marco Bruno & Lars Lundell
Pancreatic Cancer Case
Case presentation
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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
Pancreatic Cancer Case
Question 1
What would you do?
1)
send patient direct for Whipple’s surgery
2)
before considering surgery first do ERCP to
image stricture en drain the biliary tree
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
Pancreatic Cancer Case
Question 2
Would you consider EUS?
1)
yes, to confirm the presence of the lesion and
non involvement of the vessels
2)
yes, to confirm diagnosis by means of fine
needle aspiration
3)
no, has no added value to CT scan
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?
Pancreatic Cancer Case
Question 3
If CT shows a relationship with the portal vein.
Would you still consider surgery?
1)
always surgery with vascular resection and portal
vein reconstruction unless full circumferential
involvement and narrowing
2) depends on the extent of involvement
3)
do EUS to confirm involvement and then deny
resection
4)
surgery is not indicated; palliative treatment
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 Gastrointest Surg. 2010 : ahead of publ.
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 Gastrointest Surg. 2010 : ahead of publ.
Pancreatic Cancer Case
Question 4
If it turns out that the tumour can not be resected
radically at exploration, what would you do?
1)
still resect the tumour; this is the best palliation
2)
perform a gastrojejunostomy and
hepaticojejunostomy
3)
4)
Only perform a gastrojejunotomy
Close the abdomen and deal with biliary and
gastric outlet obstruction endoscopically
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
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
1
Gastrointest Endosc 2010 : 71; 490-499
Pancreatic Cancer Case
Question 5
How do you deal with a malignant biliary
obstruction in unresectable pancreatic cancer?
1)
2)
3)
Always place a plastic stent
4)
Surgical bypass in cases with expected long
survival
Always place a metal stent
Metal only in case of fast occlusion of plastic stent
or expected long survival
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
1
Eur J Gastroenterol 2007: 19; 1041-2
Pancreatic Cancer Case
Question 6
Do you offer patients with unresectable pancreatic
cancer (palliative) chemotherapy?
1)
2)
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
3) Yes, there is enough scientific proof of efficacy to
justify its routine use
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 Clin Oncol 2007: 25; 2607-15
Cochrane Database Syst Rev 2006:3
World J Gastroenterol 2007: 13; 224-7