Management of unresectable pancreatic ductal cancer

Abstract

1 The median duration of survival for patients with unresectable pancreatic ductal cancer is 6 to 10 months. 2 Given this modest duration of survival, quality of life is an important clinical end point in the management of patients with unresectable pancreatic ductal cancer. Relief or palliation of biliary tract and gastroduodenal obstruction and pain are the major clinical issues affecting quality of life. 3 Multiple therapeutic approaches have been evaluated for the management of biliary tract and gastroduodenal obstruction. Choice of therapeutic approach is dictated by the temporal recognition of unresectability. Two broad groups of patients with unresectable pancreatic cancer are (1) the majority of patients with unresectable pancreatic ductal cancer recognized nonoperatively (by imaging) and (2) the minority of patients with unresectable pancreatic ductal cancer recognized intraoperatively. 4 The preponderance of controlled and uncontrolled studies strongly support the consensus that endoscopic biliary stenting provides optimal relief of jaundice in patients with unresectable pancreatic ductal cancer recognized nonoperatively. Percutaneous transhepatic stenting is reserved for patients in whom endoscopic stenting has failed or is precluded technically. When sectable pancreatic ductal cancer is recognized intraoperatively, controlled and uncontrolled data support operative bilioenteric bypass, regardless of prior biliary stenting. 5 Accumulated data support open gastroenterostomy for palliation of gastroduodenal obstruction. Data are insufficient for consensus on prophylactic gastroenterostomy during operative bilioenteric bypass. 6 Pain adversely affects quality of life in a majority of patients with unresectable pancreatic ductal cancer; pain control improves quality of life. Both controlled and uncontrolled data support the consensus that both operative and percutaneous neurolytic celiac plexus block are more effective than oral analgesia for relief of pain. 7 Antineoplastic therapy—irradiation, chemotherapy, and immunotherapy—currently have limited impact on overall duration of survival. Controlled data for combined irradiation and systemic chemotherapy and chemotherapy alone show overall survival is improved by a few months. Sparse data on immunotherapy do not support a survival benefit. There are insufficient controlled or uncontrolled data to support a consensus on a standard antineoplastic therapeutic regimen for patients with unresectable pancreatic ductal cancer. 8 Future studies of patients with unresectable pancreatic ductal cancer should address objective measures of quality of life and survival. Stage of disease and specific symptoms should be carefully defined for patients in studies.