Pancreatic Cancer



Fig. 17.1
Proposed diagnostic algorithm for pancreatic cancer






17.7.2 Serological Diagnosis


The current broadly used serological marker for the diagnosis of pancreatic cancer in clinical practice is carbohydrate antigen 19.9 (CA19-9), which is a sialylated Lewis A-active pentasaccharide detected on the surface of mucins in pancreatic cancer patients serum. Although elevated CA19-9 levels have been associated with the presence of pancreatic or biliary cancer, there are many benign situations in which this marker is increased [136]. CA19-9 is not a suitable marker to be used in screening of asymptomatic subjects for pancreatic cancer, due to its relatively poor sensitivity and specificity. CA19-9 is considered a helpful tool in differential diagnosis of pancreatic cancer from chronic pancreatitis with high sensitivity and specificity [137, 138]. As early recurrence can be expected in patients with high preoperative levels of CA19-9, measurement of CA19-9 has a significant prognostic value before the therapeutic decision of resection, while persistent elevated marker levels after resection are indicative of remnant disease [139141]. CA 19-9 may serve as an in vivo marker for chemoradiotherapy sensitivity [142]. Additionally, CA19-9 values can be useful in distinguishing benign from malignant intraductal papillary mucinous tumors [143]. The diagnostic value of CA19-9 is limited in obstructive jaundice [144]. Overall, CA19-9 is not an adequate marker for the diagnosis of patients with pancreatic cancer, and according to the American Society of Clinical Oncology Tumor Markers Expert Panel, CA19.9 is recommended only for monitoring response to treatment [145, 146].

Although other promising markers have been reported for pancreatic cancer diagnosis, none of them has entered clinical use. This is mainly due to low sensitivity or specificity of these markers. The specific pathophysiology and micro-architecture of pancreatic cancer, which is poorly vascularized, might prevent certain molecules from passing into the circulation. Additionally, combining existent tumor markers with new ones, did not provide applicable panels [147]. Markers that have been investigated in diagnosis of pancreatic cancer include the carbohydrates CA 50, CA 125, CA 195, and CA 72-4. Other proteins, like MIC-1, PAM4, OPN, HSP27, TPS, TSGF, CAM17.1, PF4, and CEACAM1 have been studied with encouraging results, although not showing superiority to CA19-9. Consequently, despite testing many markers or their combinations, none of them has been implemented for clinical routine use besides CA 19-9 [148]. As curative resection is only possible in early stages of pancreatic cancer, an urgent need for novel serum markers for pancreatic cancer screening still remains.



17.8 Treatment Options


Pancreatic cancer is a complex disease with a wide diversity of patient population. Optimal multidisciplinary treatment approach much depends on a careful and accurate initial staging. Patients with limited disease extent (mainly Stage I/II disease) will be serious candidates to undergo surgical resection followed by adjuvant therapy or neoadjuvant therapy, albeit the latter still remains controversial. However, it might be the treatment of choice for the Stage III borderline resectable cancers prior to resection. Patients with Stage III locally advanced disease may be treated with chemotherapy and/or chemoradiotherapy, although, carefully selected patients can still be considered for surgical resection. Yet, the vast majority of these patients will develop metastatic disease. Patients with Stage IV disease and good performance status (PS) may proceed to systemic therapy, while those with poor PS shall be given best supportive care (BSC).


17.8.1 Localised Disease-Surgical Perspective


Although patients with localized PDAC disease will most benefit from a complete resection of the primary lesion, a number of different factors can affect the decision of surgery when selecting patients. The systemic nature of PDAC at diagnosis, the relatively low chance of long-term survival and the impact of pancreatectomy on quality of life are factors that need to be carefully assessed. Since the majority of these patients have locally invasive and/or micrometastatic disease at the time of operation, they run a high risk of both local and systemic recurrence following an operation with a potentially curative intent and a significant morbidity in 40–65 % of patients and mortality up to 5 % [149, 150]. Furthermore, despite improvements in surgical techniques over the last decades and perioperative patient care, pancreatic surgery is still associated with substantial perioperative morbidity and in-hospital mortality as well as significant impact on complete recovery to a normal quality of life, which can take up to 2–3 months even in the absence of any complication.

This is also important to consider for the formulation of a management plan and the implementation of neoadjuvant therapy through patient evaluation by a multidisciplinary team. Several factors, including stage, overall performance status, tumor biology, influence the final decision and significant comorbidities and age (>70 years) can determine the ability of a patient to tolerate a major operation or a neoadjuvant approach [151]. Extensive metastatic disease at the time of diagnosis, locally infiltrative and rapidly progressing tumors indicate aggressive biology and in general, patients even with an early-stage but aggressive tumor biology are unlikely to benefit from local therapy such as surgical resection. Although, there is still no validated marker to characterize this aggressive biology, low serum CA19-9 levels and wild-type SMAD4 gene status can identify patients with a more favorable tumor profile.

The appropriate operation required for a given patient is mainly determined by the location of the tumor. Pancreaticoduodenectomy (Whipple operation) is the surgery of choice for lesions arising in the head of the pancreas, while a distal pancreatectomy with an en bloc splenectomy may be required for tumors in the tail. However, masses of the neck and body may require a pancreaticoduodenectomy, distal pancreatectomy or, rarely, a total pancreatectomy. Other partial resections, like central pancreatectomy or enucleation techniques do not result in an sufficient lymphadenectomy and are not considered to have a potentially intent. Minimally invasive approaches offer, at least in theory, the merits of less scarring, less postoperative pain, less wound complications, and an earlier return to normal activity and despite the complexity of most pancreatectomies have recently been gaining ground, albeit their role in the management of patients with pancreatic cancer is not yet clear [152]. Pancreaticoduodenectomy morbidity rate has discouragingly remained between in the range of 45 %, even at high volume centers, where results show significantly better outcomes. The common postoperative morbid complications include delayed gastric emptying (15 %), wound infection (8 %), pancreatic fistula (5 %), cardiac events (4 %), abdominal abscess (4 %), bile leakage (4 %), haemorrhage (4 %), sepsis (2 %) and all other complications in less than 2 % of patients. The median survival rate still lingers in less than 2 years (18 months) with a 5-year survival of around 20 %. Negatively affecting factors include positive resection margin, histological grade and tumor size of 3 cm or greater (HR 1.6, p < 0.001) and regional lymphadenopathy (HR 1.3, p = 0.05) [153]. However, emerging non-operative biliary decompression and endoscopic therapies such as stents and non-invasive celiac plexus blocks have facilitated the drastic reduction of elective surgical palliation.


17.8.2 Neoadjuvant Therapy


Neoadjuvant therapy remains controversial in pancreatic cancer treatment , although theoretically it presents many advantages, especially in borderline resectable tumors. Among the advantages, it is considered that preoperative chemotherapy allows an early treatment of micrometastatic disease and may also induce tumour regression, reducing the risk of R1 resection or relapse after surgery. Other potential advantages include a reduced risk of peritoneal tumour implantation during surgery, and the chance of an in vivo assessment of tumour chemosensitivity. Finally, neoadjuvant treatment allows a better patient selection identifying those patients for whom surgery is unlikely to provide any benefit [12]. However, several studies have shown that resection after neoadjuvant chemoradiation (CRT) is associated with increased postoperative stay. It is finally important to note that in order to initiate neoadjuvant therapy, histological confirmation of pancreatic adenocarcinoma is required, unlike surgical resection [154].

Several studies have evaluated the role of neoadjuvant chemotherapy, radiotherapy, or combination of both in resectable pancreatic cancer. A phase II randomized trial studying patients with resectable PDAC receiving gemcitabine alone or a combination of gemcitabine with cisplatin, showed that the response rate and overall survival (OS) were better in combination arm [155]. Neoadjuvant CRT with gemcitabine concomitant to RT was studied on patients with localized pancreatic cancer. Median OS for the whole patients population was 22.7 months while patients who underwent surgery had a median OS of 34 months [156]. A phase II trial evaluated the combination of cisplatin and gemcitabine followed by gemcitabine-based CRT in patients with resectable PDAC. The median OS of all patients from the date of diagnosis was 17.4 months while patients who completed CRT and underwent surgery had a median OS of 31 months [157]. Also paclitaxel in combination with radiotherapy has been tested in patients with resectable PDAC, with moderate results [158]. Overall, patients who completed neoadjuvant CRT and underwent surgery had a higher chance of achieving R0 resection and a higher overall survival when compared to patients from historical data that underwent surgery without receiving therapy. Nevertheless, CRT may not effectively decrease distant metastasis, as shown by the high rate of distant failure in these studies. Consequently, the role of neoadjuvant therapy in patients with resectable pancreatic cancer has not yet been clearly defined. Prospective controlled randomized trials are needed so as to estimate the benefit of neoadjuvant strategies compared to conventional adjuvant strategies. Presently, the use of neoadjuvant therapies should be considered in the context of a multidisciplinary approach, in order to identify patients at high risk for recurrence.

Borderline resectable pancreatic cancers (BRPC) have been recently defined as cancers with limited involvement of the mesenteric vessels. In this setting, resection may be technically possible, but carries a higher risk of R1 resection and early recurrence. Chemoradiotherapy is a common approach in such cases and seems to improve the percentage of patients undergoing radical resection. In a study, 7 out of 18 of BRPC patients who received gemcitabine-based chemoradiotherapy were finally resected. Chemoradiotherapy did not increase perioperative morbidity and mortality [159]. In another study, patients were treated with gemcitabine, docetaxel, and capecitabine followed by 5-FU based chemoradiotherapy with IMRT. Eleven patients (64.7 %) out of 17 underwent resection and eight patients (47 %) achieved an R0 resection. The median progression-free survival and OS were 10.48 months and 15.64 months, respectively [160]. Forty borderline resectable pancreatic cancer patients were treated with combined capecitabine-based chemoradiation. A total of 16 patients (46 %) proceeded to surgery, with 88 % having an R0 resection and median overall survival of 23 months [161]. A chemoradiotherapy regimen including gemcitabine and oxaliplatin on 68 BRPC and locally advanced pancreatic cancer (LAPC) patients was studied, and R0 resection was achieved in 36 of 43 patients that underwent surgery. The median overall survival was 18.2 months for all patients and 27.1 months for those who underwent resection [162]. The benefit of neoadjuvant therapies in BRPC was retrospectively reviewed between 1999 and 2006. Patients received neoadjuvant chemotherapy followed by radiation in combination with either 5-fluorouracil (5-FU), gemcitabine, capecitabine, or paclitaxel. Patients who completed the whole therapy including surgery had a significantly better clinical outcome (median OS of 40 months), compared to a median survival of 13 months in unresected patients. These results confirm a positive effect of neoadjuvant treatment in this setting, however, the high rates of disease relapse claim for more effective future treatments [163].

In LAPC patients, neoadjuvant gemcitabine-based combinations have proved to induce higher response rates compared to single agent gemcitabine [164]. A phase II trial, evaluated gemcitabine and oxaliplatin combination in LAPC patients, and after treatment, 39 % of patients underwent curative resection, with a 69 % of R0 resections. Median OS of patients who underwent tumor resection was 22 months compared with 12 months for those without resection [165]. In another study, patients received either cisplatin, epirubicin, 5-fluorouracil/capecitabine, and gemcitabine or the same regimen with docetaxel substituting epirubicin for 6 months, followed by radiotherapy. A high response rate was observed (47 %) while stable disease was reported in 42 % of patients [166]. A recent systematic review evaluating 111 trials that included 4,394 pancreatic cancer patients, suggested that neoadjuvant treatment may be able to induce conversion to resectability in about one-third of LAPC patients [167]. In patients with borderline resectable or nonresectable pancreatic cancer, neoadjuvant therapy may achieve down-sizing of the tumour, increasing the probability of R0 resections. Current data is not sufficient to define an optimal regimen in this setting. Combination chemotherapy appears to achieve higher response rates, while there is no strong evidence to support that chemoradiotherapy is superior to chemotherapy alone. More effective chemotherapeutic regimens, like FOLFIRINOX and nab-paclitaxel, are now tested, but the efficacy of these treatments remains to be determined in prospective clinical trials.


17.8.3 Adjuvant Treatment



17.8.3.1 Practice Establishing Studies


Despite the intensity of the approaches with curative intent, PDAC demonstrates very high rates of both locoregional, most commonly the superior mesenteric artery margin, and distal recurrence necessitating postoperative therapy in the effort to reduce this risk. Patients typically need a period of 6–8 weeks to recover or might take even longer, much depending on the occurrence of adverse events. The optimal adjuvant treatment for PDAC patients remains elusive and there is still no worldwide consensus on which regimen is more effective than others, however, 6 months of a 5-FU–based or gemcitabine-based chemotherapy is an appropriate standard option. Application of 5-FU- or gemcitabine-based chemoradiation (CRT) (45 Gy directed to the tumor bed, surgical anastomoses and peripancreatic nodes with an additional 5–15 Gy boost to the tumor bed) during the postoperative period could be considered an option for R1 resections and patients whose risk of locoregional recurrence is higher. Moreover, the optimal time and sequence of AT is still debatable, yet, since the vast majority of patients will relapse with synchronous distant metastases, systemic treatment gains a priority followed by CRT, should the patient remain disease free after completion of chemotherapy [3].

In spite of the recent advances in the metastatic setting (discussed later in the metastatic disease), adjuvant treatment has lagged behind and despite that a variety of different agents and their combinations have been tested 5-FU or gemcitabine-based scheme remains the golden standard. Historical trials established the role of adjuvant therapy, however, have not managed to definitely address issues like optimal sequence, modality and regimen [168170]. Next generation studies have evaluated the benefit of adjuvant systemic chemotherapy. The CONKO-001 multicenter randomized phase III trial from the group at Charite Onkologie Group in Germany randomized 368 patients to either adjuvant intravenous gemcitabine for a total of 6 cycles or observation, achieving nearly a doubling of median disease-free survival (DFS) (13.4 vs 6.9 months, respectively; p < 0.001), and improved median OS (22.8 vs 20.2 months, p = 0.005) thus establishing its pivotal role in the management of patients in this setting [171]. Another study recently with a very similar design randomized 119 Japanese patients to receive either adjuvant gemcitabine or resection only with comparable results to the CONKO-OO1 trial [172]. However, despite the fact that median DFS was significantly improved (median DFS, 11.4 vs 5.0 months; HR = 0.60 (95 % CI: 0.40–0.89); p = 0.01), with an acceptable toxicity profile, the trial failed to show an OS improvement (median overall survival, 22.3 vs 18.4 months; HR = 0.77 (95 % CI: 0.51–1.14); p = 0.19). Differences in the sample size, the number of cycles of chemotherapy, weeks from operation to randomization and inclusion criteria regarding tumor markers applied.

The European Study Group for Pancreatic Cancer (ESPAC) investigators similarly conducted a study comparing GEM vs 5-FU (ESPAC-3v2) [173]. This was originally designed as a three-arm study, in which patients were randomized to receive a 6-month course of 5FU/LCV (leucovorin), the same duration of GEM or observation alone. However, as data emerged from other adjuvant trials regarding the benefits of adjuvant chemotherapy for PDAC, the observation alone arm was dropped. Still, ESPAC-3 represents the largest trial of its kind with a total of 1,088 patients randomized between the two treatment arms of bolus 5-FU daily with leucovorin for 5 days every 4 weeks or GEM weekly for 3 weeks every 4 weeks for 6 cycles in total. The OS was 23.0 months in the 5-FU group and 23.6 months in the gemcitabine group, with higher rates of stomatitis and diarrhea in the 5-FU group and higher rates of hematologic toxicity in the gemcitabine group, but without any difference in quality of life. Taken together, the CONKO and ESPAC trials established both 5-FU and GEM as effective options for adjuvant chemotherapy. Yet, the median OS for patients with resected pancreatic cancer dishearteningly remains approximately 20–22 months.

The role of adding radiation therapy in the adjuvant setting is still controversial and debatable between the coasts of the Atlantic. The Gastrointestinal Tumor Study Group (GITSG) trial in the 1980s was the first trial to show a survival benefit for adjuvant chemoradiation [168]. In this trial, patients with resected pancreatic cancer were randomized to either observation or to chemoradiation. Chemoradiation included a 40-Gy split course of radiation with a 2-week break after 20 Gy, given with concurrent bolus 5-FU (500 mg/m2 on days 1–3 of each 20-Gy course of RT), followed by additional weekly 5-FU for 2 years or until progression. The median OS was 21 months in the treatment arm compared to 11 months in the observation arm (adjusted p = 0.03) and actuarial 2-year survival rates (43 % vs 18 %). Criticism however arose for the relatively low RT dose, the small number of patients, and the fact that 25 % of the patients on the treatment arm did not begin postoperative treatment for more than 10 weeks following resection, mostly secondary to poor or delayed postoperative recovery. Following closure of the study, an additional 30 patients were registered on the combined modality arm and a subsequent report that included these and the original 43 confirmed the initial survival benefit. The European Organization for Research and Treatment of Cancer (EORTC) trial randomized patients to observation or to chemoradiation with 40-Gy split course given identically to the GITSG trial, with continuous infusion 5-FU (25 mg/kg/day) during the first course of radiation therapy, and for 0, 3, or 5 days of the second course (depending on toxicities) [169]. Although the OS was 12.6 months in the observation arm compared to 17.1 months in the treatment arm, this difference was not statistically significant neither was the 5-year survival (22 % vs 28 % for control and treated patients, respectively, p = 0.208). However unlike the GITSG trial patients did not receive maintenance chemotherapy.

A third large multicenter trial (ESPAC-1; n = 289) examined the role of both CHT and CRT in this setting [170]. The study used a 2-by-2 factorial design whereby patients were randomly assigned after surgery to 1 of 4 options: CHT alone, CRT alone, CRT followed by CHT or neither. It is worthwhile mentioning that ESPAC-1 used the GITSG RT regimen (AP/PA split course 20/10 + 20/10, although up to 60 Gy could be given, physician judging the final treatment dose), as did also the researchers in the EORTC trial. The four arms were ultimately combined in two comparison groups: CHT vs no CHT and CRT vs no CRT. With approximately 71 patients in each arm, patients who received CHT (5FU/LCV) had a significantly improved median OS over no treatment arm (20.1 vs 15.5 months, respectively; p = 0.009). Surprisingly enough, patients on the CRT arm had a trend towards worse outcome (median OS: 15.9 vs 17.9 months, respectively; p = 0.05). Interestingly, CRT did not reduce the risk of local relapse in this study. Investigators of the ESPAC-1 trial concluded that although CHT should be embraced as the standard of care following PDAC resection, CRT should not routinely be used, due to its deleterious effect. Of note, this study was heavily criticized because of a great deal of nonadherence within the trial, the suboptimal delivery and dosing of RT that potentially negated any survival benefit conferred by CRT with longer time-to-treatment in the CRT group and inclusion of R1 patients.

A separate study (RTOG 9704) conducted in the United States by the Radiation Therapy Oncology Group (RTOG) compared GEM with bolus 5-FU in the postoperative setting, in an effort to improve on chemoradiation therapy; patients on both arms received CRT (5040 cGy with concurrent continuous 5-FU infusion) between their first and second cycles of prescribed CHT [174]. Notably, for tumors located in the pancreatic head (388 out of 451 patients), those in the GEM group had a non statistically significant benefit in median OS that became more pronounced on multivariate analysis (p = 0.05), with 3-year survival rates of 31 % vs 22 % in the 5FU group. Despite an initial trend to survival benefit for GEM, there has been no difference noticed in OS between GEM and 5FU at closure, whereas it has demonstrated a significantly more toxic profile (Grade 4 hematologic; 5-FU 1 % vs GEM 14 %). It has to be noted that despite criticism regarding difficulties in data interpretation due to surgical and pathology issues resulting from the lack of standardization, RTOG has established the importance of CA 19-9 in the management of PDAC patients, demonstrated improved local failure compared to earlier studies (25 % for the gemcitabine arm and 30 % for the 5-FU arm) and implied that higher radiation doses might be more effective in preventing local recurrence. The primary mode of failure, however, remained distant metastasis, occurring in >70 % of patients, which highlights the need for better systemic therapies.

The limited systemic therapy options in the adjuvant setting have been expanded by a breakthrough phase III randomized trial with GEM versus S-1 for patients with resectable disease (The Japanese Adjuvant Study Group of Pancreatic Cancer; JASPAC-01 study) after the safety and efficacy committee recommended early reporting of the results [175]. The study enrolled 385 Japanese patients with stage II and III disease over a period of 3 years and achieved its primary endpoint to prove S- 1 non-inferior to GEM (p < 0.0001 for non-inferiority, p < 0.0001 for superiority). The 2-year survival rates were 70 % vs 53 % for S-1 and GEM, respectively, with lower relapse rates in the S-1 arm. The 2-year relapse free survival rates were 49 % vs 29 % for S-1 and GEM, respectively and S-1 proved to be well-tolerated, with over 70 % of patients completing the therapy and significantly fewer deaths. The S-1 emerges as a potential alternative to standard GEM-based adjuvant CHT with the limitation of S-1’s broad application in the West, secondary to metabolic differences between Asian and Caucasian ethnic groups, requiring use of potentially lower doses of the drug for Caucasian patients, as gastrointestinal side effects of S-1 are more severe among them. One possible explanation for this difference is that the pharmacokinetics are affected by polymorphisms in cytochrome CYP2A6 and consequently 5-FU concentrations in the plasma are more likely to be elevated in patients from Western countries. Hence, S-1 could be considered an alternative treatment option for populations of Asian origin, but still needs to be attested in appropriately de- signed trials, before it is immediately available for use to non- Asian populations.

Improvements in the delivery of radiation therapy now also offer more hope and newer technologies such as IMRT or SBRT that use multiple, modulated beams of radiation can limit the dose to surrounding normal structures and organs at risk and deliver higher doses of radiation to the tumor bed. The increased use of more 3-dimensional (3D) conformal planning has led to more focused radiation fields, and it has now become feasible to deliver higher doses of continuous chemoradiation without increasing toxicities. Data presented from 2 high-volume surgical centers combined, Johns Hopkins University and Mayo Clinic, reported on 1,272 patients who had undergone surgical resection for pancreatic cancer and received postoperative CRT with a median dose of 50.4 Gy [176]. Both studies combined and independently demonstrated an improved survival and increased locoregional control with chemoradiation when compared to surgery alone (median survival 21.1 vs. 15.5 months, p < 0.001; 2- and 5-year OS 44.7 vs. 34.6 %; 22.3 vs. 16.1 %, p < 0.001). Chemoradiation merits were once again more evident in margin-positive and node-positive. Yet, this once more did not address the ongoing issue of optimal adjuvant modality, where the role of chemoradiation is less clear, leaving chemo-based systemic treatment as the upfront management plan [177].


17.8.3.2 Novel and Future Postoperative Approaches


Several smaller trials have also looked at other systemic therapies and used combinations of agents that have shown efficacy in the metastatic setting. The CAPRI trial integrated immunomodulation in the evaluation of adjuvant chemotherapy with 5FU versus CRT using cisplatin, interferon alpha-2b and 5FU, followed by 5FU [178]. One hundred twenty two patients were randomized, the median survival for 5FU/LCV was 28.5 months (95 % CI, 20.4–38.6 months), and the 2-year survival rate was 54 % over a recruitment period of 3 years. The chemoradioimmunotherapy regimen has negatively affected the quality of life, because of its profound grade III/IV toxicity. Despite trial’s failure to show any significant difference with respect to OS, the 3.6-month longer median survival underlines the potentially beneficial role of this experimental regimen for selected patients and raised questions on the importance and time of surgery as well as predictive marker innovation. Based on their biological properties numerous different agents, including taxanes, oral fluoropyrimidines, epothylons and targeting molecules, have been tested alone or in several combinations, yet, despite the initially promising results the majority failed to incorporate into practice and its use is rendered questionable.

Most recent data suggest that future perspectives have to focus on patient selection and more personalized approaches in an attempt to address the dispute over best treatment option. Low matrix metalloproteinase-7 (MMP-7) serum levels predicted an OS benefit from adjuvant GEM (HR = 1.39 (1.05–1.83), p = 0.0001), but not 5-FU, implementing that patients with low MMP-7 serum levels might have a better chance benefiting from adjuvant GEM rather than 5FU [179]. MMP-7 is involved in the breakdown of extracellular matrix (ECM), tissue remodeling and plays a critical role in tumor progression via activation, degradation and shedding of non-ECM. An immunotherapy approach integrated to standard treatment seems promising, safe and demonstrates an OS that compares favorably with already published data in the literature for resected pancreatic cancer. Hyperacute immunotherapy approach (Algenpantucel-L) combined with chemotherapy (mean 12 doses, range 1–14) has been tested in the adjuvant setting demonstrating survival benefit (the 12-month disease-free survival was 62 %, and the 12-month overall survival was 86 %) [180]. The agent is well tolerated with a favorable toxicity profile and there is currently interest to evaluate its effectiveness for upfront use in multimodality approach in a phase III trial. A single-center phase II study, of 5-FU based chemoradiation combined with a pancreatic cancer vaccine of irradiated granulocyte-macrophage colony stimulating factor (GM-CSF) transfected allogenic whole-cell tumor lines conducted, has resulted in a median OS of 24.8 months (95 % CI, 21.2–31.6) and patients who showed a CD8+ T-cell response to post-immunotherapy induction mesothelin demonstrated a higher likelihood of achieving prolonged disease free status. Additional boost immunotherapy given at regular intervals beyond 1 year postoperatively offer innovative concept in the treatment of respectable disease. Other vaccines such as K-Ras mutant vaccines and MUC1 peptide-loaded dendritic cell vaccines also have shown early promising results that need however to be reproduced in larger scale trials.

The integration of predictive and prognostic biomarkers in the management of PDAC is of paramount importance since it can facilitate the recognition and selection of those patients who will benefit the most and stratify patients into optimal disease management. Genomic analysis and research into the cellular uptake of GEM suggests that levels of human equilibrative nucleoside transport protein 1 (hENT1) alters resistance and predict sensitivity to the treatment, while expression of other ribo- nucleotide reductase 1 (RRM2) and excision repair cross complementing gene 1 (ERCC1) are independent prognosticators associated with reduced relapse free survival (RFS) and OS after resection of pancreatic cancer [181]. Deleted in Pancreatic Cancer locus 4 (DPC4)/SMAD4 tumor suppressor gene status at initial diagnosis may contribute to patient selection. Loss of SMAD4 expression was highly correlated with widespread metastasis resulting in poor prognosis, whereas intact SMAD4 expression was highly correlated with a locally destructive phenotype [95]. C-X-C chemokine receptor type 4 (CXCR-4) is another independent negative prognostic factor and a predictor of distant relapse suggesting that anti-CXCR4 targeting therapies could be a promising approach in combination with cytotoxic chemotherapy in the adjuvant setting [182]. A growing body of evidence has established the role for systemic chemotherapy in the adjuvant setting and there is cumulative rise in knowledge of cellular and molecular biology. Vigorous efforts have been made to evaluate less toxic regimens and incorporate new agents into our arsenal against a disease with ominous prognosis even at earlier stages.


17.8.4 Systemic Treatment for the Metastatic Disease


Despite the improved understanding of pancreatic cancer biology, the early detection rate remains low. Almost 70 % of patients are diagnosed with advanced disease upon diagnosis and there is no doubt that systemic chemotherapy remains the standard of care in our armamentarium. The available data for first line treatment are robust (OS: 6–11 months), meanwhile the evidence for second line treatment is supported mainly by phase II and retrospective studies with poor survival expectancy (OS: 3–9 months) [183].


17.8.4.1 Chemotherapy



Gemcitabine Monotherapy and Combination Regimens

By the landmark study of Burris et al. in 1997, gemcitabine (GEM) became the standard of care. 63 patients received GEM vs. bolus 5-fluorouracil (5-FU) (n = 63). Survival (5.6 vs. 4.4 months, p = 0.0025) and clinical benefit (regarding performance status and pain management, 23.8 vs. 4.8 %, p = 0.0022) were observed [184].

Combination therapies involving platinum analogs, 5-FU, and other agents have been investigated in phase II and III trials. However, most of these failed to reveal a significant survival benefit, and only improvement in PFS and ORR was revealed [185]. Therefore, the combination approach remains a matter of debate. Furthermore, the major criticism relates with studies’ underpowered statistical design. In this context, meta-analyses performed comparing GEM alone vs. GEM+cytotoxic or GEM+platinum analog or GEM+5-FU showed risk reduction for the combination arms (HR: 0.91; 95 % CI, 0.85–0.97/HR: 0.85; 95 % CI: 0.76–0.96, p = 0.010/ HR: 0.90; 95 % CI: 0.81–0.99, p = 0.03, respectively). No risk reduction was derived by GEM-Irinotecan combination [186, 187]. GEM + Docetaxel+Capecitabine (GTX) combination showed encouraging results in retrospective studies with median (m) OS reaching 11.3 months [188]. Prospective studies are warranted to evaluate the efficacy of this promising regimen.

Reni and collaborators investigated the cisplatin, epirubicin, 5-FU, GEM regimen (PEFG) vs. monotherapy. Improved survival at 1 year (38.5 vs. 21.3 %) and in addition PFS at 4 months (60 vs. 28 %, HR: 0.46) for the combination arm were reported [189]. Moore et al. evaluated the combination of erlotinib to GEM. A statistically significant improvement of PFS (HR = 0.77, p = 0.004) and OS (HR =0.82, p = 0.038) derived, but the improvement in m OS (6.24 vs. 5.91 months) was clinically meaningless and debatable. It should be also noted that patients with a rash grade >2, usually developed during the first 2–4 weeks of treatment, had the greatest benefit compared with the patients without rash (10.5 vs. 5.3 months) [190]. In addition, GEM plus cetuximab or inhibitors of angiogenesis combinations (aflibercept, axitinib, bevacizumab, sorafenib, sunitinib) failed to show any benefit [191194]. Unfortunately, phase III studies failed to confirm phase II encouraging data focusing on angiogenesis pathway.

Von Hoff and coworkers investigated the nab-paclitaxel and GEM combination vs. GEM alone in MPACT trial. Eight hundred sixty one patients were studied. For the combination arm clear superiority was demonstrated with regard to m OS (8.5 vs. 6.7 months, HR: 0.72; 95 %, 0.62–0.83; p < 0.001), m PFS (5.5 vs. 3.7 months, HR: 0.69; 95 % CI, 0.58–0.82; p < 0.001) and RR (23 vs. 7 %, p < 0.001). Grade 3 or higher most common events were neutropenia (38 vs. 27 %), neuropathy (17 vs. 1 %) and fatigue (17 vs. 7 %) [195]. The rationale of nab-paclitaxel administration is based on SPARC (secreted protein acidic and rich in cysteine) protein binding which is overexpressed in the cancer microenvironment. Thus nab-paclitaxel by depleting tumor stroma renders a high concentration of chemotherapeutic agent in the tissue [196, 197].


5-FU/Capecitabine Combination Regimens

The continuous 5-FU infusion and Oxaliplatin combination vs. single arms of both 5-FU and Oxaliplatin offered benefit with regard to mOS (9 vs. 2.4 vs. 3.4 months, respectively) [198]. Furthermore, similar results were derived by the comparison of CapOx vs. CapGEM vs. GEMOX for PFS (4.2, 5.7, 3.9) and OS (8.1, 9, 6.9 months, respectively) [199]. Further studies evaluated protracted vs. bolus 5-FU and combination with Cisplatin or Mitomycin C [200, 201]. No survival improvement was revealed.


Irinotecan Doublet Combinations

In a phase II study, by a FOLFIRI regimen clear benefit was derived for OS, PFS and ORR [202]. On the contrary, GEM+ Irinotecan regimens did not offer any improvement [203].


FOLFIRINOX Combination

In PRODIGE 4/ACCORD 11, a randomized phase III trial, conducted by Conroy and collaborators, a three drug combination FOLFIRINOX (infusional 5-FU/folinic acid, irinotecan, oxaliplatin) was evaluated vs. GEM alone. Improvement was derived for OS (11.1 vs. 6.8 months, HR: 0.57, p < 0.001), PFS (6.4 vs. 3.3 months, HR: 0.47, p < 0.001) and ORR (31.6 vs. 9.4 %, p < 0.001). Grade 3 or higher most common events for the combination arm were neutropenia (45.7 vs. 21 %, p < 0.001), febrile neutropenia (5.4 vs. 1.2 %, p = 0.03), sensory neuropathy (9 vs. 0, p < 0.001) and diarrhea (12.7 vs. 1.8, p < 0.001) [204].


17.8.4.2 Immunotherapy


The unmet medical need to improve survival in pancreatic cancer patients directed research to investigate the field of immunotherapy. Unfortunately, promising data obtained by phase I and II studies of MUC1, CEA antigen pulsed dendritic cell vaccines or a telomerase peptide vaccine (GV1001) with GM-CSF did not translate into a statistically and clinically survival improvement when tested in phase III studies [205208]. Preliminary results in a phase IB study that investigated GVAX [irradiated pancreatic cancer cells modified to elude granulocyte-macrophage colony-stimulating factor (GM-CSF) and produce an anti-tumor immune response] + Ipilimumab vs Ipilimumab alone appeared encouraging (5.5 vs. 3.3 months) [209]. GVAX and CRS207 (a listeria based vaccine) translated to a survival benefit (6.1 vs. 3.9 months, HR: 0.59, p = 0.0172) which was more clear among patients treated in third line (5.7 vs. 3.9 months, HR: 0.29, p = 0.0003) [210].


17.8.4.3 Future Directions


Targeting the stroma that interferes with the weak drug penetration and confers chemo-resistance appears an attractive target. Sonic Hedgehog pathway plays an important role in this context. In addition, TGF-B – instead of its critical role in pathogenesis, metastasis and angiogenesis – is an important partner in stromal regulation. Furthermore, the Notch pathway, Histone de-acetylation and DNA hypermethylation are thought to be important targets in pancreatic cancer. Results of PARP inhibitors in patients with BRCA1,2 mutations, and clarification of data on metformin’s use are strongly awaited.

Although various therapy combinations have been found to improve survival expectancy significant toxicity is often associated. Young patients or in good performance status are candidates for GEM+ nab-paclitaxel or FOLFIRINOX combinations. To those with modest or poor performance status single agent GEM could be the option. Moreover, for patients with poor performance status best supportive care could be the alternative.


17.9 Palliation



17.9.1 Quality of Life


Pancreatic cancer carries a dismal prognosis at even the early stage and patients usually have a limited follow-up before they progress on to a more advanced stage. Therefore, much attention is focused upon palliation and symptom control and the decision to treat a patient with more aggressively must always take into account the impact upon a patient’s quality of life (QoL). Toxicities from treatment may also contribute to the patient’s symptom profile despite any clinical benefit response deriving from it. Several comprehensive report forms exist to evaluate patient’s QoL, however, EORTC has developed a disease specific QoL module for pancreatic cancer (EORTC QLQ-PANC26), which has 26 questions and must be used in conjunction with the generic instrument EORTC Quality of Life Questioinnaire-C30 (EORTC C-30). Yet, its utility is strongly restricted both in research and clinical practice, since patients particularly with severe and disabling disease as it is often difficult to complete. Supportive management of symptoms must be initiated early and aggressively to ensure patient comfort with early involvement of the palliative care facilities [211].

Pancreatic cancer frequently presents with pain even as initial symptom at the time of diagnosis. Initial assessment of pain should include evaluation of the intensity, frequency, duration, exacerbating and/or alleviating factors as well as a comprehensive history of current and previous pain medications along with documentation of any side effects encountered on these medications. This should be completed by clinical examination to influence decisions on implementation of the appropriate pharmacologic or procedural interventions. Patient symptoms may also complement as prognostic signs for treatment success and mortality and their response to symptom control may act as predictors of disease extent and response [212].

Albeit, palliative care or pain team should be actively involved in the management of symptoms like pain, the attending physician should be trained and feel comfortable starting the initial analgesic regimen. Opioids are generally thought the mainstay of pharmacologic management of pancreatic cancer pain. Initial therapy shall preferably consist of a short-acting opioid such as morphine or oxycodone. Collateral comorbidities of the patient like chronic kidney damage and/or hepatic impairment should also be taken into account when selecting the appropriate agent. A sustained-release opioid, along with a short-acting opioid for breakthrough pain, may be the next step of actions mainly in patients whose pain has been roughly under control, those with constant pain or those sleeping problems due to pain. Common side effects of opioids include sedation, constipation, pruritus, nausea, xerostomia and testosterone suppression in those on long-term therapy. Constipation is commonly addressed with stool softeners or bowel motility-promoting agents.

However, more advanced techniques might be needed for pain control. The most common and effective procedural intervention for is celiac plexus block [213]. Patients with pain refractory to increasing doses of opioids and those who suffer debilitating opioid-mediated side effects seem to benefit most from a celiac plexus block. Most patients relish a >3 month period of pain relief on initial celiac plexus neurolysis yields, yet, subsequent celiac plexus neurolysis may be feasible in selected patients, its efficacy is seriously mitigated by disease progression. More invasive techniques such as intrathecal delivery of analgesia, via an implantable intrathecal drug delivery systems (IDDSs), might prove helpful especially for patients who have not achieved adequate pain relief. IDDSs managed to control pain, significantly relieve common drug toxicities, and improve survival in patients with refractory cancer pain [214].

Physical symptoms like fatigue, anorexia, cachexia, gastric outlet obstruction, insomnia, decreased appetite, dysgeusia, indigestion and certainly pain heavily impact on pancreatic cancer patients’s psychology. Additionally fear of disease recurrence, severity or advanced stage is pervasive and can render the patient emotionally unstable. Depression is a common condition up to one fifth of patients and become debilitating since data suggest that patients who are depressed are more likely to have suboptimal treatment or poor response. Notably, depression may as well precede initial diagnosis raising that this might equally be a result of chemicals released by the tumor and not just a consequence of the psychological burden of the diagnosis [215]. Regardless of etiology, appropriate early detection and treatment is of paramount importance for the immense suffering it causes.


17.9.2 End of Life


Pancreatic cancer is a disease with a grim natural history and albeit the aim for health care providers is prolonging life, assisting patients and their families when in distress through the arduous transitions precipitating all too often is equally as important. The multidisciplinary team decision to discontinue treatment is equally disappointing most of the times for both patients and their families as it is for doctors and it should involve patient, family, friends, and the healthcare team. However, it is important to clarify that ending cancer treatment does not necessarily mean ending care. A hospice placement is frequently recommended when prognosis is no longer than 6 months. It addresses all aspects of a patient and family’s needs, including the physical (eg, pain relief), psychological, social, and spiritual or may be given at home. Nowadays, advanced services such as hospital to home care also exist and facilitate the serene transition to home reducing their suffering.


Synopsis: Take Away Messages

It is the twelfth most common cancer type but the seventh cause of death due to cancer with 10–20 % familial or hereditary cases and increasing incidence. It carries one of the highest incident-to-mortality rates among cancer types with almost 39 people being diagnosed and 38 dying from the disease every hour around the world. Lifestyle factors like tobacco use, alcohol, obesity and diet form significant risk factors. Several medical conditions and hereditary diseases predispose to pancreatic cancer as does the occurrence of other cancer types. Point mutations, especially of the KRAS family do occur and drive oncogenesis through the MAP-kinase pathway in addition to Tumor Suppressor Gene inactivation such as p16, p53, DPC4/SMAD inactivation and BRCA2 mutations. The research on further molecular events in pancreatic carcinogenesis (overexpression of EGFR, VEGF, MMPs, COX-2, hedgehog signaling, IGF-1 pathways) has not yet manage to produce any fruit in clinical practice. Resectable and early stage disease still carries the best chances of long-term survival and by that we mean mostly small tumors mainly in the head of the pancreas without any extrapancreatic spread, patent SMV and PV, definable tissue plan between the tumor and regional arterial structures (including the celiac axis and SMA). Neoplasms of the tail are considered of high risk for peritoneal seeding despite their potentially smaller size. Yet, locoregional and distant recurrence frequency reaches 80 %.

Systemic treatment established by a German group (CONKO-001) and several meta-analyses demonstrated superiority of postoperative gemcitabine compared to surgery alone for patients with resected pancreatic cancer and is the mainstay of adjuvant therapy in Europe; however, combined CRT is preferred in the USA, based on historical trials and single center experiences. Based on ESPAC-3 both weekly gemcitabine and 5-FU/LV can be considered appropriate adjuvant treatment. CRT might have a role to play in node positive, borderline resectable or palliation in advanced unresectable disease. Targeted therapies have largely failed to produce any substantial outcome. The interest for treatment of the metastatic disease has been revived by the introduction of combinations like FOLFIRINOX and nab-paclitaxel for patients with good performance status, absence of biliary obstruction and no infectious complications after addressing the problem of significant expected toxicity. Other alternatives with combination capecitabine and GEM or GEM single agent have conferred some modest benefits. Treatment on relapse or progression is not equally well established, but second line options include 5-FU-based regimens, such as FOLFOX, FOLFIRI or even single-agent capecitabine in patients who cannot tolerate combination treatments.

The majority of patients present with a wide variety of symptoms, which need to be addressed early on and patient and their family requires receiving support, both physical and psychological. Early Palliative Care and Pain team involvement is highly recommended, since prognosis is dismal and relapse highly likely. Health care professionals and attending clinicians need to be actively involved and a network of professional is required to promptly address patient’s needs. Course of events and overall management plan should involve a variety of specialties within the MDT. MDT shall also take the decision for no further oncologic treatment and arrange for patient’s appropriate placement for end of life therapies.


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Mar 25, 2016 | Posted by in INTERVENTIONAL RADIOLOGY | Comments Off on Pancreatic Cancer

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