Endoscopic approach to early diagnosis of pancreatic cancer

Peroral Cholangioscopy: How Technology and Imaging Have Changed ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is the minimally invasive standard of care for the treatment of several biliary and pancreatic pathologies. One of the limitations of this technique is the lack of endoluminal vision within the biliary tree or Wirsung's duct. This limits the diagnostic accuracy of the procedure and reduces the effectiveness of many treatments. Technological progress and the use of increasingly ergonomic and high-definition imaging equipment have led to the dissemination of peroral cholangioscopy (POC). Thanks to the high quality of video image resolution, POC could well be a powerful tool used to characterize malignant biliary strictures. It could also allow targeted biopsies or local treatments, hence reducing the risk of complications and increasing outcomes. The technological improvement of the last generation of POC is opening new horizons in the treatment of biliopancreatic pathologies, thereby contributing to refine and enhance the ERCP management of several diseases in the near future.

Non-invasive biomarkers in pancreatic cancer diagnosis: what we need versus what we have

Pancreatic cancer (PC) is probably the most lethal tumor being forecast as the second most fatal cancer by 2020 in developed countries. Only the earliest forms of the disease are a curable disease but it has to be diagnosed before symptoms starts. Detection at curable phase demands screening intervention for early detection and differential diagnosis. Unfortunately, no successful strategy or image technique has been concluded as effective approach and currently non-invasive biomarkers are the hope. Multiple translational research studies have explored minimally or non-invasive biomarkers in biofluids-blood, urine, stool, saliva or pancreatic juice, but diagnostic performance has not been validated yet. Nowadays no biomarker, alone or in combination, has been superior to carbohydrate antigen 19-9 (CA19-9) in sensitivity and specificity. Although the number of novel biomarkers for early diagnosis of PC has been increasing during the last couple of years, no molecular signature is ready to be implemented in clinical routine. Under the uncertain future, miRNAs profiling and methylation status seem to be the most promising biomarkers. However, good results in larger validations are urgently needed before application. Industry efforts through biotech and pharmaceutical companies are urgently required to demonstrate accuracy and validate promising results from basic and translational results.

Contribution of microRNA analysis to characterisation of pancreatic lesions: a review

Pancreatic tumours are usually very aggressive cancer with a poor prognosis. A limitation of pancreatic imaging techniques is that lesions are often of ambiguous relevance. The inability to achieve a definitive diagnosis based on cytological evaluation of specimens, due to sampling error, paucicellular samples or coexisting inflammation, might lead to delay in clinical management. Given the morbidity associated with pancreatectomy, a proper selection of patients for surgery is fundamental. Many studies have been conducted in order to identify specific markers that could support the early diagnosis of pancreatic lesions, but, to date, none of them allow to diagnose pancreatic cancer with high sensitivity and specificity. MicroRNAs (miRNA) are small non-coding RNAs (19-25 nucleotides) that regulate gene expression interacting with mRNA targets. It is now established that each tissue shows a characteristic miRNA expression pattern that could be modified in association with a number of different diseases including neoplasia. Due to their key role in the regulation of gene expression, in the last years several studies have investigated miRNA tissue-specific expression, quantification and functional analysis to understand their peculiar involvement in cellular processes. The aim of this review is to focus on miRNA expression in pancreatic cancer and their putative role in early characterisation of pancreatic lesions.

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Role of endoscopic retrograde pancreatography for early detection of pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm of the pancreas

BACKGROUND

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is often found with distinct pancreatic ductal adenocarcinoma (PDAC) in the same pancreas. The aim of this study was to clarify whether endoscopic retrograde pancreatography (ERP) would be useful for the early detection of concomitant PDACs in patients with IPMNs.

METHODS

Medical records of 179 patients who were histologically confirmed to have IPMNs after resection between 1987 and 2011 were reviewed. The patients having concomitant PDACs were selected, and the diagnostic abilities to detect concomitant PDACs of computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS), and ERP were compared between early (stages 0-I according to Japanese General Rules for Pancreatic Cancer) and advanced (stages II-IV) PDACs.

RESULTS

A total of 23 PDACs developed synchronously or metachronously in 20 patients, and the prevalence of PDACs concomitant with IPMNs was 11.2 % (20/179). Sensitivities of CT (16 vs. 87 %), MRI (29 vs. 93 %), and EUS (29 vs. 92 %) in the early group were significantly lower than those in the advanced group (p < 0.01). On the other hand, the sensitivity of ERP in the early group was as high as that in the advanced group (86 vs. 82 %, respectively, p > 0.99). Among 7 early PDACs, 3 were diagnosed only by ERP.

CONCLUSIONS

ERP has an important role in the early diagnosis of distinct PDACs in patients with IPMNs. Further investigation is necessary to clarify the indication and the timing of ERP during management of IPMNs in term of early detection of concomitant PDACs.

Magnetic Resonance Imaging Duodenoscope

A side-viewing duodenoscope capable of both optical and magnetic resonance imaging (MRI) is described. The instrument is constructed from MR-compatible materials and combines a coherent fiber bundle for optical imaging, an irrigation channel and a side-opening biopsy channel for the passage of catheter tools with a tip saddle coil for radio-frequency signal reception. The receiver coil is magnetically coupled to an internal pickup coil to provide intrinsic safety. Impedance matching is achieved using a mechanically variable mutual inductance, and active decoupling by PIN-diode switching. (1)H MRI of phantoms and ex vivo porcine liver specimens was carried out at 1.5 T. An MRI field-of-view appropriate for use during endoscopic retrograde cholangiopancreatography (ERCP) was obtained, with limited artefacts, and a signal-to-noise ratio advantage over a surface array coil was demonstrated.

Outcomes after preoperative endoscopic ultrasonography and biopsy in patients undergoing distal pancreatectomy

BACKGROUND

This retrospective cohort study analyzes the potential risks associated with preoperative fine needle aspiration (FNA) biopsy guided by endoscopic ultrasonography (EUS) in patients undergoing distal pancreatectomy.

METHODS

Excluding 204 patients with acute or chronic pancreatitis and those with previous pancreatic resections, 230 consecutive patients with primary pancreatic neoplasms underwent elective distal pancreatectomy between 2002 and 2009. The most common indications were adenocarcinoma (28%), intraductal papillary mucinous neoplasm (IPMN; 20%), and endocrine neoplasms (17%). Two-way statistical comparisons were performed between patients who did (EUS(+)) or did not (EUS(-)) undergo preoperative EUS-FNA.

RESULTS

Distal pancreatectomy was performed open in 118 patients (56%) and laparoscopically in 102 patients (44%). No differences were observed in age, sex, American Society of Anesthesiologists class, operative time, or blood loss between the EUS(+) (n = 179) and EUS(-) (n = 51) groups. Splenectomy was performed in 162 patients (70%) and was more common in the EUS(+) group. With the exception of adenocarcinoma (n = 57 [32%] EUS(+) vs n = 6 [12%] EUS(-); P < .01), the final pathologic diagnosis did not differ significantly between the EUS groups. Postoperative complications were more common in the EUS(+) patients with cystic neoplasms (43% vs 16% EUS(-); P = .04). EUS-FNA caused pancreatitis in 2 patients preoperatively. No differences in overall or recurrence-free survival were noted between cancer patients in the EUS groups. Patterns of tumor recurrence were not associated with EUS-FNA.

CONCLUSION

Preoperative EUS-FNA is not associated with adverse perioperative or long-term outcomes in patients undergoing distal pancreatectomy for solid neoplasms of the pancreas. The potentially detrimental long-term impact of preoperative EUS-FNA in patients with resectable pancreatic adenocarcinoma was not observed, but will require additional study.

Dynamic quantitative evaluation of contrast-enhanced endoscopic ultrasonography in the diagnosis of pancreatic diseases

OBJECTIVES

This study aimed to investigate the usefulness of contrast-enhanced endoscopic ultrasonography (EUS) with time-intensity curve (TIC) in differentiating pancreatic diseases.

METHODS

Patients who underwent contrast-enhanced EUS between January 2007 and June 2009 were analyzed retrospectively, including 48 with pancreatic ductal cancer (PC), 14 with autoimmune pancreatitis (AIP), 13 with mass-forming pancreatitis (MFP), and 16 with pancreatic endocrine tumor (PET). After intravenous injection of contrast agent, contrast imaging pattern, TIC-based quantitative evaluation, and diagnostic ability of EUS in combination with TIC to diagnose benignancy or malignancy were assessed.

RESULTS

Hypovascular and heterogeneous pattern (42/48) in PC, isovascular and homogenous (21/27) in AIP and MFP, and hypervascular and rapid stained (16/16) in PET were observed. The echo intensity reduction rate from the peak at 1 minute was the greatest in PC followed by MFP, AIP, and PET (P < 0.05). The diagnostic accuracies based on contrast imaging pattern (84.0%) and TIC (88.0%) were higher than those based on B-mode imaging (82.6%) and dynamic computed tomography (81.3%). In EUS in combination with TIC, sensitivity, specificity, and accuracy rose up to 95.8%, 92.6%, and 94.7%, respectively.

CONCLUSIONS

Contrast-enhanced EUS with the dynamic quantitative analysis preparing TIC increased the diagnostic accuracy for pancreatic diseases.

Role of pancreatic endoscopic ultrasonography in 2010

Endoscopic ultrasonography (EUS) was introduced 25 years ago aiming at better visualization of the pancreas compared to transabdominal ultrasonography. This update discusses the current evidence in 2010 concerning the role of EUS in the clinical management of patients with pancreatic disease. Major indications of EUS are: (1) Detection of common bile duct stones (e.g. in acute pancreatitis); (2) Detection of small exo- and endocrine pancreatic tumours; and (3) Performance of fine needle aspiration in pancreatic masses depending on therapeutic consequences. EUS seems to be less useful in cases of chronic pancreatitis and cystic pancreatic lesions. Moreover the constant improvement of computed tomography has limited the role of EUS in pancreatic cancer staging. On the other hand, new therapeutic options are available due to EUS, such as pancreatic cyst drainage and celiac plexus neurolysis, offering a new field in which new techniques may arise. So the main goal of this review is to determine the exact role of EUS in a number of pancreatic and biliary diseases.

Diagnosis of pancreatic tumors by endoscopic ultrasonography

Pancreatic tumors are highly diverse, as they can be solid or cystic, and benign or malignant. Since their imaging features overlap considerably, it is often difficult to characterize these tumors. In addition, small pancreatic tumors, especially those less than 2 cm in diameter, are difficult to detect and diagnose. For characterizing pancreatic tumors and detecting small pancreatic tumors, endoscopic ultrasonography (EUS) is the most sensitive of the imaging procedures currently available. This technique also provides good results in terms of the preoperative staging of pancreatic tumors. EUS-guided fine needle aspiration (EUS-FNA) has also proved to be a safe and useful method for tissue sampling of pancreatic tumors. Despite these advantages, however, it is still difficult to differentiate between benign and malignant, solid or cystic pancreatic tumors, malignant neoplasms, and chronic pancreatitis using EUS, even when EUS-FNA is performed. Recently, contrast-enhanced EUS with Doppler mode (CE-EUS) employing ultrasound contrast agents, which indicate vascularization in pancreatic lesions, has been found to be useful in the differential diagnosis of pancreatic tumors, especially small pancreatic tumors. However, Doppler ultrasonography with contrast-enhancement has several limitations, including blooming artifacts, poor spatial resolution, and low sensitivity to slow flow. Consequently, an echoendoscope was developed recently that has a broad-band transducer and an imaging mode that was designed specifically for contrast-enhanced harmonic EUS (CEH-EUS) with a second-generation ultrasound contrast agent. The CEH-EUS technique is expected to improve the differential diagnosis of pancreatic disease in the future. This review describes the EUS appearances of common solid and cystic pancreatic masses, the diagnostic accuracy of EUS-FNA, and the relative efficacies and advantages of CE-EUS and CEH-EUS along with their relative advantages and their complementary roles in clinical practice.

A pilot study of urokinase-type plasminogen activator (uPA) overexpression in the brush cytology of patients with malignant pancreatic or biliary strictures

We have previously demonstrated that uPA is overexpressed in pancreatic tumors. In an attempt to diagnose these tumors earlier, we sought to determine whether uPA could be identified in endoscopic retrograde cholangiopancreatography obtained brushings in patients with malignant pancreatic and biliary strictures. Secondarily, uPA was measured in the serum of this patient population. uPA overexpression was identified in the cytologic tissue in 8 of 11 patients (72.7%). Serum analysis demonstrated a 2-fold higher concentration of uPA in the pancreaticobiliary cancer patients (1.27 versus 0.56 ng/mL; P = .0182). Also, uPA overexpression correlated with serum levels (P < .0001). This study confirms that uPA can be detected in the ERCP cytologically obtained tissue and is frequently present in a higher concentration in the serum of pancreaticobiliary cancer patients. A larger sample size will be required to address its value as a sensitive marker for the diagnosis of pancreatic or biliary cancers.

Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage

BACKGROUND

Pancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD).

METHODS

A total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively.

RESULTS

The overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES.

CONCLUSIONS

Invasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.

Utility of contrast-enhanced endoscopic ultrasonography for diagnosis of small pancreatic carcinomas

The aim of our study was to assess the utility of endoscopic ultrasonography (EUS) and contrast-enhanced EUS (CE-EUS) for the depiction and differential diagnosis of pancreatic tumors focusing in particularly those 2 cm or smaller. We compared different diagnostic procedures, contrast-enhanced multidetector computed tomography (CE-CT) and EUS with the use of power Doppler (PD-EUS) and CE-EUS for detection and differential diagnosis of pancreatic tumors. The study included 156 consecutive patients with suspected pancreatic tumors, who underwent CE-CT, and EUS followed by PD-EUS and CE-EUS. CE-EUS was performed by power Doppler mode using sonographic contrast agent Levovist. Thirty-six of 156 patients examined had tumors of < or =2 cm. EUS had significantly higher sensitivity (94.4%) for detection of pancreatic carcinomas of 2 cm or less in comparison to CE-CT (50%). For small pancreatic tumor of 2 cm or less, sensitivities for differentiating ductal carcinomas from other tumors were 50.0%, 11.0% and 83.3% for CE-CT, PD-EUS and CE-EUS. CE-EUS was significantly more sensitive than PD-EUS and CE-CT. EUS and subsequent CE-EUS are more sensitive than CE-CT in the detection and the differentiation of small pancreatic tumors.

Clinicopathological study on the intraductal spread of small pancreatic cancer

BACKGROUND

The aim of this study was to evaluate histopathologically the frequency, direction, and length of intraductal spread (IS) along the main pancreatic duct from the main tumor of small pancreatic cancer.

METHODS

Resected specimens from 20 cases of pTS1 (histologically 2 cm or less in diameter) pancreatic cancer (September 1983 to December 2005) were examined histopathologically. As controls, 40 resected specimens from cases of pTS2 (more than 2 cm and less than 4 cm in diameter) or larger sized pancreatic cancer (pTS2<or=) were examined in the same manner. The specimens were evaluated histopathologically as to (1) the prevalence of IS, (2) the direction and length of IS, and (3) the positive rates of transpapillary cytology of pure pancreatic juice (TPC) and biopsy of the main pancreatic duct (TPB), performed preoperatively.

RESULTS

IS was observed in 45% of pTS1 and 13% of pTS2<or= cases. In 88% of cases of pTS1, IS was observed in the direction of the ampullary side. In 40% of cases of pTS2<or=, IS toward the ampullary side was seen. The mean length of IS in pTS1 and pTS2<or= cases was 11.8 mm and 7.2 mm, respectively. Positive rates of TPC and TPB in pTS1 cases were 70% and 75%, respectively, and in pTS2<or= cases, 50% and 44%, respectively.

CONCLUSIONS

The frequency of IS was high in pTS1 cases, which suggests there is potential for improvement in establishing the histocytological diagnosis of small pancreatic cancer via the transpapillary approach with the development of adequate tools.

Interpreting trends of pancreatic cancer incidence and mortality: a nation-wide study in Sweden (1960-2003)

OBJECTIVE

We investigated temporal trends of pancreatic cancer in Sweden measured with suboptimal sensitivity and specificity both by incidence and by mortality rates.

METHODS

46,257 incident cases of pancreatic cancer from the Swedish Cancer Register and 53,686 mortality cases from the Causes of Death Register during 1960-2003 were used to calculate age-standardized incidence or mortality rates. We further assessed the impact of changes in diagnostic practice on the observed trends, and investigated the effect of calendar period and birth cohort by age-period-cohort modeling.

RESULTS

Overall, the pattern of trends in age-adjusted rates of pancreatic cancer was similar irrespective of whether incidence or mortality was used. The age-adjusted rates of pancreatic cancer increased during the first decade and then peaked for both sexes (the male peak occurred in the early 1970s and the female peak in the 1980s) followed by a steady decline in both groups. An age-period model provided the best fit to the observed trends among patients diagnosed at ages 35-74 in both sexes.

CONCLUSION

The close agreement between the incidence and mortality and the gender disparity suggest a true decline in pancreatic cancer incidence in recent years in Sweden, and gender-specific trends in exposure to environmental risk factors.

Current treatment strategies for pancreatic cancer in the elderly

Pancreatic cancer, which is responsible for >90% of exocrine pancreatic tumours, is typically a disease of the elderly (> or =70 years of age). However, older patients are less likely to be staged than younger patients despite having a worse overall 5-year survival rate than their younger counterparts. Various radiological, ultrasonographic and endoscopic investigations are used not only as diagnostic tools but also to accurately stage the cancer for possible surgery. Many patients with pancreatic cancer have mutations of the K-ras oncogene, and various tumour suppressor genes are also inactivated. Pancreas resection can be performed in elderly resectable patients without excess mortality, even in those >80 years of age. However, treatment for locally advanced, unresectable and metastatic pancreatic cancer is palliative. Fluorouracil-based chemoradiation for locally advanced or unresectable cancer, and gemcitabine for patients with metastatic disease, can result in clinical benefits. Placement of a stent in the biliary tract has been shown to improve symptoms of obstructive jaundice or ascites, as well as quality of life. As molecular targets are identified, interventions with targeted specific agents may improve tumour control. However, further studies will be needed to demonstrate whether or not various agents targeting signal transduction pathways or nuclear transcription factors are useful for elderly patients with advanced pancreatic cancer.

Clinical Results on Intra-arterial Adjuvant Chemotherapy for Prevention of Liver Metastasis Following Curative Resection of Pancreatic Cancer

BACKGROUND

We report here the clinical results of intra-arterial adjuvant chemotherapy for the prevention of liver metastasis following curative resection of pancreatic carcinoma.

METHODS

Twenty-two patients with pancreatic cancer underwent the radical operation between January 1999 and April 2005. Intra-arterial adjuvant chemotherapy with cisplatin (CDDP) and 5-fluorouracil (5FU) was selectively performed on nine patients; the remaining 13 patients did not receive chemotherapy and comprised the control group.

RESULTS

Demographics and clinical characteristics were almost identical in the two groups. Liver metastasis occurred in three of nine patients (33%) in the chemotherapy group and in seven of 13 patients (54%) in the control group. The intra-arterial adjuvant chemotherapy had the tendency to suppress the rate of liver metastasis. The median survival period was 15.8 months for the nine patients who underwent the intra-arterial adjuvant chemotherapy following surgery and 13.4 months for the 13 patients of the control group who were curatively resected without the intra-arterial adjuvant chemotherapy. Cumulative survival rate was improved by the intra-arterial adjuvant chemotherapy.

CONCLUSIONS

In patients with pancreatic cancer who underwent the curative operation, the intra-arterial adjuvant chemotherapy had the tendency to suppress the rate of liver metastasis and improve cumulative survival.

Diagnóstico y estadificación del carcinoma de páncreas (I)

Carcinoma of the pancreas is a neoplasm with a poor prognosis that is diagnosed in the advanced stages in most patients. Given that surgical resection is the only potentially curative treatment for this disease, it is of the utmost importance to appropriately select the group of patients with initial stage pancreatic tumors that have not extended and can therefore be resected. Several different imaging techniques can be used for this purpose: ultrasonography (US), computed tomography (CT), magnetic resonance (MR), as well as the recent additions of endoscopic ultrasonography (EUS) and positron emission tomography (PET). Other techniques, such as laparoscopy and laparoscopic ultrasonography, also play a role in the diagnosis and staging of these patients. Continual technological developments in each of the above-mentioned techniques have led to reiterated updates in the scientific literature throughout the last two decades. This review aims to evaluate each of these techniques and present diagnostic algorithms reflected in the literature in order to achieve the greatest diagnostic accuracy in determining the extent of the disease so that unnecessary surgery can be avoided in cases not susceptible to resection.

The inherited genetics of pancreatic cancer and prospects for secondary screening

It is estimated that pancreatic cancer has a familial component in approximately 5-10% of cases. Some of these cases are part of a defined cancer syndrome with a known gene mutation but in the remaining the causative gene remains unknown. In recent years, a better understanding of the molecular events that occur in the progression model of pancreatic cancer has lead to the development of secondary screening programmes with the aim of identifying early precursor lesions or pre-invasive cancer at a stage amenable to curative resection. High-risk groups who have an inherited predisposition for pancreatic cancer form the ideal group to study in developing a robust screening programme. Multimodality screening using computed tomography and endoluminal ultrasound in combination with molecular analysis of pancreatic juice are proving promising as diagnostics tools or at least serving as predictors of risk over a defined period.

Contrast-enhanced endoscopic ultrasound in discrimination between focal pancreatitis and pancreatic cancer

AIM: To evaluate the contrast-enhanced endosonography as a method of differentiating inflammation from pancreatic carcinoma based on perfusion characteristics of microvessels.

METHODS: In 86 patients with suspected chronic pancreatitis (age: 62 ± 12 years; sex: f/m 38/48), pancreatic lesions were examined by conventional endoscopic B-mode, power Doppler ultrasound and contrast-enhanced power mode (Hitachi EUB 525, SonoVue^®, 2.4 mL, Bracco) using the following criteria for malignant lesions: no detectable vascularisation using conventional power Doppler scanning, irregular appearance of arterial vessels over a short distance using SonoVue^® contrast-enhanced technique and no detectable venous vessels inside the lesion. A malignant lesion was assumed if all criteria were detectable [gold standard endoscopic ultrasound (EUS)-guided fine needle aspiration cytology, operation]. The criteria of chronic pancreatitis without neoplasia were defined as no detectable vascularisation before injection of SonoVue^®, regular appearance of vessels over a distance of at least 20 mm after injection of SonoVue^® and detection of arterial and venous vessels.

RESULTS: The sensitivity and specificity of conventional EUS were 73.2% and 83.3% respectively for pancreatic cancer. The sensitivity of contrast-enhanced EUS increased to 91.1% in 51 of 56 patients with malignant pancreatic lesion and the specificity increased to 93.3% in 28 of 30 patients with chronic inflammatory pancreatic disease.

CONCLUSION: Contrast-enhanced endoscopic ultrasound improves the differentiation between chronic pancreatitis and pancreatic carcinoma.

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Advances in the Genetic Screening, Work-up, and Treatment of Pancreatic Cancer

Familiarity with the updated results in genetic screening and work-up presented here is essential to early diagnosis and possible cure. In the metastatic setting, we most frequently begin with the GTX regimen, consisting of Gemcitabine, Taxotere, and Xeloda. The regimen is based on our laboratory data demonstrating a synergistic increase in cell killing of pancreatic cancer cell lines. The combination takes advantage of the selective cell cycle effects of each of the three drugs. In our initial experience, we have seen a response rate of 40% at metastatic sites and 31% at the primary site after nine cycles of GTX. We are now conducting a formal phase II protocol to confirm these results. The median survival of this group of patients (at least 10.4 months) is as long as, or longer than other currently used regimens. In those patients who do not tolerate GTX or progress despite the regimen, we have found that a regimen of the same three drugs, administered on a different schedule, can produce responses. In the neoadjuvant (unresectable) setting, we treat with GTX initially and then follow with radiation; gemcitabine is used as a radiosensitizer during this treatment. An aggressive surgical approach with a team of surgeons were able to resect for cure 12 of the 16 patients who were initially unresectable; one year survival of these 12 was 100%; 2 year survival was 50%. Future work in this disease should focus on targeted agents such as bevacizumab.