Cerrahi Sonrasi Tedavi Secenekleri...

Adjuvant therapy for pancreatic ductal adenocarcinoma (treatment given after resection) improves both median and long-term survival. In the past decade, gemcitabine in combination with 5-fluorouracil (5-FU) based chemoradiotherapy has become the adjuvant treatment of choice. This regimen has been shown to improve median and long-term survival when compared with surgery alone in the largest trial of resected patients in North America (RTOG 97-04). In contrast, the largest European trial has shown no benefit to the chemoradiotherapy (ESPAC-1), and thus in Europe, adjuvant treatment tends to utilize chemotherapy alone. The focus in recent years has been to study combination therapies by adding other cytotoxic agents—such as capecitabine, cisplatin, or mitomycin-C—to a gemcitabine-based regimen, or by combining gemcitabine with newer molecular targeted therapies that affect specific cellular pathways, such as topoisomerase-1 inhibitors, matrix metalloproteinase inhibitors, vascular endothelial growth factor inhibitors, or epidermal growth factor inhibitors. To date, the majority of these trials have shown limited clinical efficacy with drug combinations, except for the epidermal growth factor receptor (EGFR) inhibitor erlotinib, which has shown a modest survival benefit.

With the recent mapping of the pancreatic genome, more attention is being drawn to the specific genetic alterations and major signaling pathways underlying pancreatic ductal adenocarcinoma. This may allow for the accelerated identification and development of specific targeted agents. The newest trials under development include the use of specific targeted agents such as insulin-like growth factor 1–receptor inhibitors, poly (ADP-ribose) polymerase (PARP) inhibitors, and c-Met inhibition, as well as the use of immunotherapy for the adjuvant treatment of pancreatic ductal adenocarcinoma. Many laboratories are currently working on better defining the crucial intracellular signaling pathways that are abnormal in pancreatic and other periampullary adenocarcinomas, with the focus on defining a therapeutic target specific for each resected tumor. Given the complex nature of genetic alterations in pancreatic ductal adenocarcinoma, such a personalized treatment model may be critical to developing more effective adjuvant treatment strategies.

Ameliyat Sonrasi Sag Kalimi Belirleyen Faktorler...

The most important factors affecting long-term survival following the resection of periampullary adenocarcinoma include the site of tumor origin, tumor size, histologic grade, resected lymph node status, and resection margin status. The presence of lymphovascular and perineural invasion also have negative prognostic significance, although to a lesser degree. The most potent negative predictor of long-term survival is the presence of lymph node metastases within the resection specimen. As the ratio of positive nodes to total nodes examined increases, the median and long-term survival rates decrease. Patients who undergo an R0 resection for pancreatic malignancy who have the most favorable tumor characteristics—size less than 3 cm, well-differentiated tumors, and an absence of nodal metastasis—have the most favorable outcomes, with a median survival of 4 years and a 5-year survival rate exceeding 40%.

Ve Cerrahii......

Much progress has been observed following PD in recent years, such that an operation that in the 1960s and 1970s had a mortality of 20% to 40% is now associated with an operative mortality of 1% to 3% at most high-volume institutions. Ample evidence suggests that perioperative morbidity, mortality, and median survival are improved when the procedure is performed at high-volume institutions that carry out more than 20 PDs per year; several institutions in the United States perform over 100 PDs annually. Hospital stays that commonly lasted beyond 2 weeks are now 6 to 8 days in most cases. These remarkable improvements are due not only to advances in operative technique but also in management algorithms , perioperative critical care, standardized intervention for complications, the institution of critical pathways for postoperative treatment, improvements in endoscopic and interventional radiology techniques, and increasing experience of surgeons. Despite these advancements, PD still carries a high perioperative morbidity of 30% to 40%, with the most common postoperative complications being pancreatic fistula, delayed gastric emptying, intraabdominal abscess, wound infection, urinary tract infection, and cardiac arrhythmia.

Yorumlar ; Iyi merkezlerde operasyona bagli mortalite yuzde 1 dir. 

Tedavi Sonrasi Beklentiler..

Unfortunately, most patients diagnosed with pancreatic cancer will succumb to their disease within a year or two of diagnosis. For those who are candidates for resection, recent data suggest they can expect a 5-year survival as high as 35%. Until a new method for early detection and substantially improved targeted treatment is developed, pancreatic cancer will remain a uniformly lethal condition. Patients who are not candidates for curative resection often require intervention to address complications associated with local tumor growth, to achieve improved quality of life, and to maximize the benefits of medical therapy.

Despite the fact that most pancreatic cancer patients are not candidates for surgical resection, the surgeon plays an important role in their management. A clear understanding of the interventionsavailable to mitigate the local effects of pancreatic cancer growth on the bile duct, duodenum, and celiac plexus helps to navigate the nonoperative and intraoperative approaches to palliate this group (Figure 7). When appropriate, nonoperative intervention should be the first line of treatment for unresectable patients. Biliary stenting, duodenal stenting, and percutaneous celiac plexus block are effective for palliation of patients with short life expectancies. Operative bypass can effectively address biliary and duodenal obstruction for patients who fail endoscopic therapy or who are identified as unresectable at the time of laparotomy or laparoscopy. Optimal palliation of these conditions improves quality of life, minimizes the need for hospitalization, and allows the patient to engage in palliative chemotherapy, thus maximizing survival benefit.

Yorumlar;Bbaslangic itibari ile ilk 2 yil icinde tanisi konursa , cerrahi Sonrasi 5 yillik yuzde 35 yasam sansi 

Borderline Resectabl Pancreatic Cancer..

Even though there is some consistency in the AJCC definitions of resectability, these become blurred when describing borderline resectable pancreatic adenocarcinoma. At the University of Texas M.D. Anderson Cancer Center (MDACC), patients with (anatomic) borderline resectable pancreatic cancer were originally defined to include those whose tumors exhibit: short-segment encasement of the hepatic artery which is amenable to resection and reconstruction without evidence of tumor extension to the celiac axis; abutment of the SMA to involve less than or equal to180 degrees of the circumference of the artery; or short-segment occlusion of the SMV, PV, or SMPV confluence with a suitable option for vascular reconstruction due to a normal SMV below, and PV above the area of tumor involvement (7). Since then the criteria have been extended to include additional patients where the surgery could prove to be technically challenging. The American hepato-pancreatico-biliary (AHPBA) association consensus conference on pancreatic cancer (2009) expanded the venous involvement criteria to allow tumor abutment of the SMV/PV with or without impingment and narrowing of the lumen (in addition to venous encasement or short segment occlusion). NCCN has adopted some of these AHPBA guidelines in its most recent version (2.2011) and allows SMV/portal vein abutment with impingment and narrowing of the lumen . The criteria for arterial involvement (SMA and hepatic artery) are clear and similar across the board.

The above definitions describe the anatomic subset of borderline resectability that deal only with tumor-vessel orientation (referred to as type A). Katz and colleagues have described two additional subsets, types B and C, which attempt to define additional criteria for borderline resectability beyond the imaging based principles . Most physicians encounter patients with operable pancreatic cancer who are not quite ready for immediate surgery and require extra time off to sort out host or tumor related concerns. Some of these patients have subtle indeterminate subcentimeter liver lesions or peritoneal / omental nodules that are suspicious for metastatic disease they are too small to proceed with a diagnostic FNA- biopsy or additional imaging tests (PET-CT or MRI). These patients fit the MDACC type B definition of borderline resectable pancreatic cancer. Type B patients may have had a technically resectable or a borderline resectable primary tumor as defined on CT images. Another subset of patients is those who have associated medical comorbidities that need time to evaluate or a reversible borderline performance status (typically ECOG 3). Good examples of these presentation is a patient who has a small asymptomatic pulmonary embolism on routine imaging or a patient with a low prealbumin and decline in nutrition and performance status in the presence of obstructive jaundice and cholangitis though progress is noted after biliary decompression and a close eye on nutritional supplementation. This subset constitutes Type C category (and patients in this category may also have had a radiographic potentially resectable or a borderline resectable primary tumor).

Ileri Evre Pankreas Kanserinde Vaskuler Rezeksiyonlar

Vascular resection during PD adds complexity to an already challenging operation with potential for significant morbidity and mortality. Patient selection is critically important and is largely based on CT imaging. Resectability should be defined by clear, consistent, objective anatomic criteria that must be accurately interpreted on cross-sectional imaging studies. For potentially resectable patients, the survival benefit of surgery is predicated on negative surgical margins and the successful delivery of multimodality therapy. Therefore, the surgeon must avoid inadvertent venous injury that will necessitate rapid removal of the tumor and increase the chances of an incomplete gross resection.

Preoperative planning is key; the surgeon must plan for possible vascular resection prior to surgery rather than discovering the need for revascularization in the operating room. The vascular dissection must be done in a careful fashion so that all of the relevant anatomy is clearly defined prior to attempted removal of the specimen. With adequate exposure and a controlled approach to vascular resection and reconstruction, PD with vascular resection can offer patients the chance for cure and a median survival identical to that of patients who undergo standard PD without the need for vascular reconstruction. Isolated involvement of venous structures is not a contraindication to PD, however, the procedure should be performed by experienced surgeons at high-volume centers as part of a multidisciplinary protocol-based approach to patients with pancreatic cancer.

Pankreas Kanserinin Ilk Bulgulari...

The most common presenting sign of periampullary cancer is progressive obstructive jaundice (75%). Early on, patients may note dark urine and pale stools, followed by scleral icterus and yellow skin pigmentation. Pruritis secondary to the deposition of bile salts in the skin is common. Patients may also complain of anorexia, pain, and weight loss. Occasionally, the initial symptoms may be quite vague and may include upper GI discomfort, dyspepsia, and maldigestion or steatorrhea due to pancreatic exocrine insufficiency. Other nonspecific symptoms that may occur include nausea, early satiety, abdominal fullness, discomfort, malaise, weakness, fevers, and night sweats. A new diagnosis of adult onset diabetes is noted in a minority of patients. Those patients with ampullary or duodenal adenocarcinoma may have heme-positive stools or a microcytic anemia at their initial visit, given the tendency for these tumors to bleed. Patients often complain of a dull and constant midepigastric abdominal pain that radiates to the back and is the result of chronic biliary or pancreatic duct obstruction. The presence of more severe pain that responds poorly to analgesics may reflect neural invasion of the peripancreatic autonomic plexus, which portends a poorer prognosis.

Yorumlar; Hastalarda genelde ilk bulgu sarilik, kilo kaybi, idrar da koyulasma, diski renginde acilma.    

Yeni baslayan seker hastaligida  (ailede seker hastaligi yoksa) pankreas Kanserinin bulgusu olabilir

Pankreas Kanserinde Yeni Tedavi Yaklasimlari

Pancreatic ductal adenocarcinoma is the tenth most common cancer and the fourth leading cause of cancer death in the United States. In 2008, an estimated 37,680 new cases were diagnosed, with 34,290 deaths from the disease. The peak incidence occurs in the sixth and seventh decades of life, and men and women are equally affected by this disease, which has an overall 5 year survival rate of 4%. Smoking and obesity are clear risk factors for the development of pancreatic ductal adenocarcinoma; industrial asbestos exposure, experimental radon exposure, alcohol abuse, and diabetes appear to be less clearly associated. Approximately 5% to 10% of patients are believed to have a familial form of pancreatic cancer most commonly associated with mutations in BRCA-2 (familial breast cancer), PRSS1 (hereditary pancreatitis), p16 (familial atypical multiple mole or melanoma), or HNPCC (hereditary nonpolyposis colorectal cancer).

Surgical resection via pancreaticoduodenectomy (PD) is the only potentially curative therapy; such resection improves the overall 5 year survival rate to 15% to 25%. Because of the presence of locally advanced disease, distant metastases, or significant medical comorbidities, only a minority (20% to 30%) of patients at the time of diagnosis are candidates for surgical resection, the lowest percentage among all of the periampullary malignancies.

'When it comes the cancer, biology is king , patient selection is queen and the techniques are the princes of the realm'