Current and emerging therapies for the treatment of pancreatic cancer

Abstract

Pancreatic adenocarcinoma carries a dismal prognosis and remains a significant cause of cancer morbidity and mortality. Most patients survive less than 1 year; chemotherapeutic options prolong life minimally. The best chance for long-term survival is complete resection, which offers a 3-year survival of only 15%. Most patients who do undergo resection will go on to die of their disease. Research in chemotherapy for metastatic disease has made only modest progress and the standard of care remains the purine analog gemcitabine. For resectable pancreatic cancer, presumed micrometastases provide the rationale for adjuvant chemotherapy and chemoradiation (CRT) to supplement surgical management. Numerous randomized control trials, none definitive, of adjuvant chemotherapy and CRT have been conducted and are summarized in this review, along with recent developments in how unresectable disease can be subcategorized according to the potential for eventual curative resection. This review will also emphasize palliative care and discuss some avenues of research that show early promise.

Keywords: mortality; neoadjuvant therapy; palliative care adeno carcinoma.

Figure 1

Survival of patients with pancreatic cancer categorized by the receipt of curative intent surgery. Copyright © 2007. Reproduced with permission from Shaib Y, Davila J, Naumann C, EI-Serag H. The impact of curative intent surgery on the survival of pancreatic cancer patients: a U.S. Population-based study. Am J Gastroenterol. 2007;102(7):1377–1382.

Figure 2

Downstaging with neoadjuvant therapy: 59-year-old man with a 2.2 × 1.8 cm pancreatic head mass found to be pancreatic adenocarcinoma on biopsy A) Pretreatment scan. Note severe SMV impingement, which fits criteria for borderline resectable disease B) Post-treatment scan. The patient was reated with neoadjuvant capecitabine 1500 mg po bid and concurrent radiation. The SMV is less confined; the pancreas mass remains similar in size. C) Post-operative scan. The patient underwent pancreaticoduodenectomy with jugular SMV reconstruction.

Figure 3

A) CT image after injection of a small volume of dilute contrast agent through both needles, confirming correct distribution of injected contrast around the celiac axis (arrows) prior to alcohol injection. B) After injection of alcohol, darkened region (arrow) shows its distribution in the vicinity of the celiac plexus. Copyright © 2007. Reproduced with permission from Arellano RS. Image-guided pain management, Part 1: celiac plexus block for palliative pain relief. Radiology Rounds, Vol 5. Boston, MA: Massachusetts General Hospital; 2007.