Palliation Of Pancreatic Cancer Research Articles

Endoscopic ultrasound-guided radiofrequency ablation of the pancreas: An experimental study with pathological correlation.

Background:The treatment of pancreatic cancer represents a major objective in clinical research, as it still remains the fourth leading cause of cancer deaths among men and women, with approximately 6% of all cancer-related deaths.Materials and Methods:We studied the assessment of an endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) probe through a 19G needle in order to achieve a desirable necrosis area in the pancreas. Radiofrequency ablation of the head of the pancreas was performed on 10 Yorkshire pigs with a weight between 25 kg and 35 kg and a length of 40-70 cm. Using an EUS-guided RFA experimental probe, we ablated an area of 2-3 cm width. The biological samples were harvested after 3 days and 5 days and necropsy was performed 1 week after the procedure.Results:All pigs showed no significant change regarding their behavior and no signs of complication was encountered. Blood analysis revealed increased values of amylase, alkaline phosphatase, and gamma-glutamyl transpeptidase on the 3rd day but a decrease on the 5th day. After necropsy and isolation of the pancreas, the ablated area was easily found, describing a solid necrosis. The pathological examination revealed a coagulative necrosis area with minimal invasion and inflammatory tissue at about 2 cm surrounding the lesion.Conclusion:EUS-RFA is a feasible technique and might represent a promising therapy for the future treatment of pancreatic cancer. However, further studies are necessary to investigate EUS-guided RFA as an option for palliation in pancreatic cancer until it can be successfully used in human patients.

Meta-analysis of Phase III randomized trials of molecular targeted therapies for advanced pancreatic cancer

ObjectivesFor patients with unresectable pancreatic cancer (PC), the efficacy and safety of molecular targeted agents (MTAs) in combination with gemcitabine are still unclear. Published randomized controlled trials (RCTs) have reported conflicting results. This study aimed to conduct a systematic review of the literature and to perform a meta-analysis if appropriate. MethodsSeven electronic databases were searched using a standard technique to November 2011 without restriction on publication status or language. The primary aim was to assess overall survival (OS). Secondary aims were to assess progression-free survival (PFS), overall response rates (ORRs) and grade 3, 4 and 5 toxicities. A random-effects model was used for the meta-analysis. ResultsSeven Phase III RCTs were identified; 1981 patients were treated with MTAs and gemcitabine, and 1992 patients received gemcitabine with or without placebo. No statistically significant difference in OS was found between the two groups [hazard ratio (HR)=0.93, 95% confidence interval (CI) 0.85–1.02; P=0.13]. The addition of MTAs improved PFS (HR=0.86, 95% CI 0.79–0.93; P=0.000) and ORR (odds ratio 1.35, 95% CI 1.05–1.74; P=0.01). However, these benefits were accompanied by significantly higher toxicity (P=0.001). ConclusionsThe findings of this study suggest that the palliation of PC with gemcitabine and MTAs does not provide a significant survival benefit and is associated with increased grade 3 and 4 toxicities.

Pancreatic cancer: an endoscopic perspective

Pancreatic cancer continues to be a diagnostic and therapeutic challenge. The advent of endoscopic ultrasound-guided interventions have brought about a paradigm shift in the endoscopic approach to diagnosis, treatment and palliation of this common malignancy. The last decade has witnessed significant advances in techniques of endoscopic biliary drainage, endoluminal stenting, celiac plexus neurolysis and image-guided radiation therapy, which have transformed the scope of palliation in pancreatic cancer. Moreover, endoscopic ultrasound-aided intratumoral delivery of fiducials, radioisotopes and chemotherapeutic agents have shown promising results and warrant further investigation. This review summarizes the recent advances in endoscopic applications for the management of pancreatic neoplasms.

Bypass Surgery Versus Intentionally Incomplete Resection in Palliation of Pancreatic Cancer: Is Resection the Lesser Evil?

ObjectiveAs technical expertise increases, the indication for pancreatic resection for advanced pancreatic cancer has been expanded over the last years. Recently, several groups reported their series of unintentionally incomplete tumor resections and reported a potential survival benefit for patients after incomplete resection when compared with palliative bypass surgery. We investigated in a retrospective analysis whether even tumor resection that was intended to be incomplete might provide a better outcome than conventional palliative procedures. MethodsTwenty-two patients with a locally non-resectable or disseminated adenocarcinoma of the pancreas underwent a palliative intentionally incomplete resection. Outcome after resection was compared with that of 46 patients matched for age, sex, and histopathological tumor type who underwent a palliative bypass operation. ResultsOverall surgical morbidity was significantly higher in the resection group (59%) compared with the bypass group (33%, p < 0.05), resulting in a higher relaparotomy rate and a significantly longer postoperative hospital stay (p < 0.001). Surgery-related mortality was significantly higher in the resection group (p < 0.05). Overall survival showed no statistically significant difference between the two groups. ConclusionsBecause of the higher surgery-related morbidity and mortality and lack of survival benefit in cases of advanced adenocarcinoma of the pancreas, intentionally incomplete palliative resection is not advisable.

Advances in diagnosis, treatment and palliation of pancreatic carcinoma: 1990-2010.

Several advances in genetics, diagnosis and palliation of pancreatic cancer (PC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. PC is relatively common as it is the fourth leading cause of cancer related mortality. Most patients present with obstructive jaundice, epigastric or back pain, weight loss and anorexia. Despite improvements in diagnostic modalities, the majority of cases are still detected in advanced stages. The only curative treatment for PC remains surgical resection. No more than 20% of patients are candidates for surgery at the time of diagnosis and survival remains quite poor as adjuvant therapies are not very effective. A small percentage of patients with borderline non-resectable PC might benefit from neo-adjuvant chemoradiation therapy enabling them to undergo resection; however, randomized controlled studies are needed to prove the benefits of this strategy. Patients with unresectable PC benefit from palliative interventions such as biliary decompression and celiac plexus block. Further clinical trials to evaluate new chemo and radiation protocols as well as identification of genetic markers for PC are needed to improve the overall survival of patients affected by PC, as the current overall 5-year survival rate of patients affected by PC is still less than 5%. The aim of this article is to review the most recent high quality literature on this topic.

Microscopically incomplete resection offers acceptable palliation in pancreatic cancer

Because mortality and morbidity of pancreatic surgery have decreased to acceptable levels, the complex question arises whether pancreatic resection should be performed in patients with preoperatively doubtful resectable pancreatic cancer. Perioperative parameters and outcome of 80 patients who underwent a microscopically incomplete (R1) resection were compared with those of 90 patients who underwent a bypass for locally advanced disease for pancreatic adenocarcinoma. All patients initially underwent exploratory laparotomy with the intention to perform a resection. Quality of life was assessed by analyzing readmissions and their indications. Groups were similar with respect to age, presenting symptoms, and preoperative health status. Tumors were significantly larger in the bypass group (3.5 cm vs 2.9 cm, P < .01). Hospital mortality was comparable: zero after R1 resection and 2% after bypass. Of all severe complications, only intra-abdominal hemorrhage occurred significantly more frequently after resection (10% vs 2%; P = .03). Hospital stay after resection was significantly longer than after bypass (16 vs 10 days; P < .01). Survival was significantly longer after R1 resection (15.8 vs 9.5 months, P < .01). Sixty-one percent of patients were readmitted for a total of 215 admissions, equally distributed between groups. After R1 resection, 0.58% of the total survival time after initial discharge was spent in the hospital, after bypass, 0.69%, which was not significantly different. R1 pancreatic resection and bypass for locally advanced disease can be performed with comparable low mortality and morbidity rates. Readmission rates are also comparable between groups and time spent in the hospital after initial discharge is low. Because resection offers adequate palliation in pancreatic cancer, a more aggressive surgical approach in patients who are found to have a doubtfully resectable tumor could be advocated, even if only an R1 resection can be achieved.

Laparoscopic palliation of pancreatic cancer

Laparoscopic palliation of pancreatic cancer

Palliation in pancreatic cancer: The controversies continue

Palliation in pancreatic cancer: The controversies continue

Perductal electrolytic ablation of the porcine pancreas: A minimally invasive option-studies of morbidity and mortality

Pancreatic cancer has a dismal prognosis. Few patients are suitable for surgical resection, leaving the majority requiring symptom palliation. Current palliative techniques such as surgical bypass and endoscopic retrograde cholangiopancreatography (ERCP) are imperfect. A novel palliative therapy combining the symptom control of surgical bypass with the minimally invasive nature of ERCP is required. Perductal electrolytic ablation of pancreatic tissue, in a porcine model, was performed. There were two survival groups of 2 weeks (n = 4) and 8 weeks (n = 4). Postoperatively, serum biochemistry, amylase and C-reactive protein (CRP) were assessed. Histological examination of the pancreas, lungs, and kidneys was performed to determine the presence of acute pancreatitis or systemic inflammatory response. An immediate transient increase in both amylase and CRP was seen. Although pancreatic histology demonstrated localised necrosis at the electrolytic site at 2 weeks, there was no evidence of generalized pancreatitis or a systemic inflammatory response at either 2 or 8 weeks. This study suggests that, although there is localized pancreatic necrosis and transient hyperamylasemia, perductal pancreatic electrolytic ablation is safe, with neither generalized pancreatitis nor a systemic inflammatory response, in the medium and long term. Although performed in normal porcine pancreas, because of the absence of a large-animal model of pancreatic cancer, this study suggests that electrolytic pancreatic ablation is safe. This technique may have a role in the palliation of pancreatic cancer, especially if delivered via a minimally, invasive approach, and warrants further investigation.

Pancreatic cancerEdited by John L. Cameron. 274 pp. $125.00. The American Cancer Society and BC Decker, Hamilton, Ontario, Canada, 2001. ISBN 1-55009-131-X. Web address for ordering: www.cancer.org or www.bcdecker.com

The purpose of this book is to inform the reader of the most recent advancements in pancreatic cancer. The book, however, was published in 2001, and the chapters were written in 1999 and 2000. Most references are 1999 and earlier. A few chapters have references from 2000 including molecular genetics, neoadjuvant therapy, palliation of pancreatic cancer, chemoradiation for unresectable pancreatic cancer, and management of body and tail cancers.

Prognostic factors in the palliation of pancreatic cancer

Aim: Few patients with pancreatic cancer are eligible for resection. In the remainder, estimation of prognosis is important to optimise various aspects of care, including palliation of biliary obstruction and trial of chemotherapy.The aim is to evaluate the prognostic significance of clinical and laboratory variables in patients with unresectable pancreatic cancer.Methods: Information was gathered retrospectively for 325 patients with unresectable pancreatic cancer who underwent palliative interventions, including surgical bypass, endoscopic or percutaneous stenting or who received supportive care only.Results: Histological proof was obtained in 182 patients (56%). Median survival was 5.7 months. Absence of therapeutic intervention, leukocytosis (WCC≥11×109/l), gamma glutamyl transferase (γGT)>165U/L, prothrombin time ratio ≥1.1, and C-reactive protein (CRP) ≥5mg/dL were associated with shorter survival on univariate analysis. Only absence of therapeutic intervention, leukocytosis, and γGT>165U/L reached significance on multivariate analysis. In the 51 patients in whom serum CRP was available, CRP was the only significant predictor of survival on multivariate analysis.Conclusions: Leukocytosis, elevated γGT and raised CRP predict shorter survival and may help to guide the choice of palliative intervention for patients with unresectable pancreatic cancer.

Palliation of pancreatic cancer using electrolytic ablation.

Inoperable pancreatic cancer has a dismal prognosis. Palliation involves either stenting or surgical bypass. Stenting does not relieve gastric outlet obstruction, and surgical bypass is a major procedure. A minimally invasive procedure is needed that relieves both gastric outlet and biliary obstruction, with the potential for relieving pain. In an experimental model, pancreatic electrolysis was investigated. The pancreatic duct was cannulated via a transduodenal approach with an electrode catheter. In 6 animals an electrolytic "lesion" was created using a direct current generator. Six animals were controls. The local and systemic effects of electrolysis were assessed using histological and biochemical parameters. The pancreatic duct was cannulated in all animals and treatment was uneventful. Electrolytic lesions comprised a central area of necrosis with a sharp demarcation between necrotic and viable pancreas. All animals developed transient hyperamylasemia after electrolysis. There was no significant difference between treatment and controls. Importantly, no animal had clinical, biochemical, or histological evidence of pancreatitis. This experimental study suggested that electrolytic palliation of inoperable pancreatic cancer via the gastrointestinal tract is potentially safe. In patients, this treatment could be performed during endoscopic retrograde cholangiopancreatography and may have therapeutic advantages when compared to stenting or biliary bypass.

An audit of percutaneous biliary stenting for the palliation of pancreatic cancer: Results, post-procedural survival period, and comparison of plastic and mental stents

The purpose of this retrospective study was to assess the patient survival period after palliative biliary stenting and to compare different kinds of stents used. During a 27-month period, 60 patients received palliative percutaneous biliary stents for obstructive jaundice due to carcinoma of the head of the pancreas. During the first procedure 17 patients received (metal) Wall stents (mean age 59.8 years, range 32 - 77 years), and 43 patients received (plastic) Carey Coons stents (mean age 62.3 years, range 31 - 87 years). In 12 patients the stent had to be replaced due to complications and 1 patient had a second replacement. All replacement stents were plastic except in 2 cases. Two out of 17 (11.7%) metal stents and 10 out of 43 (23.2%) plastic stents had to be replaced. The median post-procedural survival period was determined between the date of procedure and the date of death. There was a marked clinical improvement of jaundice in all patients with their follow-up within a few days. More plastic stents were replaced. The average post-procedural survival period for 41 patients was 85.6 days, which is on par with internationally accepted survival periods. The most cost-effective biliary stent must be used for palliation because of the very short survival rate of this disease. For patients with no surgical options this procedure yields excellent results in comparison with the high morbidity and mortality rates of palliative surgical bypass procedures.

Surgical palliation of pancreatic carcinoma. Results of a 7 year period

High perioperative complication rates in the 1980s led to preferred use of endoscopic therapy for surgical palliation of pancreatic cancer. This encouraged us to analyse our own patients retrospectively. In the period from 1 January 1992 to 31 December 1998, 253 patients with an exocrine carcinoma of the pancreas were operated on at the St. Elisabeth Hospital Cologne-Hohenlind: 73 patients (28.9%) underwent curative resection (R0) while 180 patients (71.1%) had palliative operative treatment (R1/R2). Palliative resection was performed in 22 patients (8.7%). Intestinal bypass surgery was done in 113 patients (44.7%) as a gastrojejunostomy and in 16 patients (6.3%) as a duodenojejunostomy. A biliodigestive anastomosis was performed in 85 patients (33.6%). This procedure was combined with a gastroenterostomy in 78 patients (30.8%). In 18 patients (7.1%) no surgical palliation was possible and the operation finished as a diagnostic laparotomy. The overall mortality rate within the first 30 (60) days was 5.5% (12.7%). Patients whose carcinoma had been resected curatively had a 30 (60)-day mortality rate of 2.7% (4.1%), compared to a rate in palliatively treated patients (resection/bypass/probatoria) of 6.7% (16.1%). Patients with palliatively resected tumor had perioperative mortality of 4.5% (4.5%), whereas patients who did not undergo resection had 6.9% (17.7%). The survival rate for curatively resected patients after Kaplan-Meier extrapolation was 64.7% after 1 year and 31.2% and 26.2% after 3 and 5 years, with a median survival time of 552 days. Palliatively operated patients had a survival rate of 19.4%, 2.5% and 0% for 1, 3 and 5 years. Median survival time was 171 days in this situation. Compared to patients without resection (17.4% and 2.0%), patients with palliative resection had survival rates for 1 and 3 years of 40% und 5.9%. After 5 years none of these patients were alive. Our data show a high success of surgical palliation in pancreatic cancer in centers with a high frequency of pancreatic surgery. Patients that could not be cured (R1/R2), although undergoing extensive procedures, had better survival rates than patients treated with bypass surgery. Perioperative mortality rate was comparatively low. This justifies aggressive surgical management of pancreatic carcinoma.

Endoscopic palliation of pancreatic cancer

There are many approaches to palliation of jaundice in patients with pancreatic cancer. Each stenting technique has merit. Regrettably, an insufficient number of randomized comparative trials using the latest technology have been performed. Moreover, economic analyses of techniques to aid in clinical decision making are few. Currently data support endoscopic stenting as the standard for most patients with obstructive jaundice from pancreatic cancer. Patients with an expected survival of more than 6 months should undergo placement of an expandable metal stent, whereas patients with a limited life expectancy (<3 months) are best served with a plastic stent. Randomized comparative studies are needed between laparoscopic techniques and endoscopically placed expandable metal stents. Percutaneous techniques may prove safer and more effective when metal expandable stents are used.

Laparoscopic gastrojejunostomy in the palliation of pancreatic cancer: reflections on the preliminary results.

The aim of this study was to assess the feasibility of laparoscopic gastroenteric and cholecystenteric bypass procedures for palliation of inoperable cancer of the pancreas. Between July 1994 and January 1996, five patients underwent laparoscopic gastroenterostomy for duodenal obstruction due to pancreatic cancer. There were four men and one woman, ranging in age from 53 to 72 years (median 63). Four patients already had endoscopic biliary decompression. One patient underwent laparoscopic cholecystojejunostomy for biliary obstruction at the time of the laparoscopic gastroenterostomy. The procedure was completed laparoscopically in all patients. There was no perioperative mortality, and the morbidity was low. The median post-operative stay was 4 days (range, 4-6). Laparoscopic gastroenterostomy associated with cholecystojejunostomy in selected cases offers a less invasive alternative than open surgery, with a shorter hospital stay and more rapid return to normal activity.

Pancreaticoduodenectomy. Does it have a role in the palliation of pancreatic cancer?

The authors define the role of palliative pancreaticoduodenectomy in patients with pancreatic carcinoma. Decreases in perioperative morbidity and mortality and improved long-term survival associated with pancreaticoduodenectomy for patients with pancreatic carcinoma have clearly established a role for this operation when performed with curative intent. However, most surgeons remain hesitant to perform pancreaticoduodenectomy unless surgical margins are widely clear, choosing rather to perform palliative biliary and gastric bypass. A single-institution retrospective review was performed comparing the outcome of 64 consecutive patients undergoing pancreaticoduodenectomy for pancreatic carcinoma with gross or microscopic evidence of adenocarcinoma at the surgical resection margins, and 62 consecutive patients found to be unresectable at the time of laparotomy because of local invasion without evidence of metastatic disease (stage III). Combined biliary and gastric bypass were performed in 87% of patients not resected. The two groups were similar with respect to age, gender, race, and presenting symptoms. The hospital mortality rate was identical in both groups (1.6%). Fifty-eight percent of patients undergoing pancreaticoduodenectomy had an uncomplicated postoperative course compared with 68% of patients undergoing palliative bypass (not significant). The length of postoperative hospital stay after pancreaticoduodenectomy was 18.4 days, which was significantly longer (p < 0.05) than for patients undergoing palliative bypass (15.0 days). The overall actuarial survival (Kaplan-Meier) was improved significantly in patients undergoing pancreaticoduodenectomy (p < 0.02). Postoperative chemotherapy and radiation therapy improved survival in both groups. Pancreaticoduodenectomy can be performed with a similar perioperative morbidity and mortality and only a minimal increase in hospital stay when compared with traditional surgical palliation. Pancreaticoduodenectomy with postoperative chemotherapy and radiation therapy is associated with improved long-term survival when compared with patients treated with surgical bypass. These data support the role of palliative pancreaticoduodenectomy in patients with pancreatic carcinoma and with local residual disease.

Palliation for pancreatic cancer

Background: Although laparoscopy reveals undetected metastases in many patients with pancreatic cancer, most surgeons have chosen to proceed directly with laparotomy in an attempt at resection or for palliation of biliary and gastric outlet obstruction. In an effort to overcome this limitation, this study attempted to determine the feasibility of laparoscopic cholecystojejunostomy and gastrojejunostomy.

Palliation of pancreatic cancer: A prospective multicentre study

The aim of this study was to compare palliation of patients with verified pancreatic carcinoma after radical surgery (n = 84), bypass surgery, i.e. biliary (n = 106), biliary and duodenal (n = 85), and for patients with advanced disease, i.e. laparotomy alone (n = 56), not operated (n = 106), 3 months after discharge from hospital. 128 of 233 patients (55%) still alive were followed up. Radically resected patients had the best palliation and clinical performance; on average they could perform normal activities if helped, 82% were mobile at home and 62% were pain-free. Bypassed patients can on average look after themselves but normal activities are not possible, 31% were in hospital, 26% were pain-free and 39% suffered from nausea and vomiting. Patients with advanced disease were on average incapable and required special help and care, about 70% were in hospital, 8-17% were pain-free. 'Good risk' bypassed patients, i.e. in stage I-III, used stronger analgesics (29 vs 3%) (P = 0.006) and more frequently complained of nausea and vomiting (38 vs 12%) (P = 0.02) than radically resected patients. Palliation was comparable for the two bypassed groups.

Improving Palliation in Pancreatic Cancer: Intraoperative Celiac Plexus Block for Pain Relief

Most patients with pancreatic carcinoma are not curable. Surgical palliation of obstructive jaundice and gastric outlet obstruction leaves many patients with severe pain from pancreatic carcinoma. Anesthesiologists have drawn increasing attention to the successful use of postoperative percutaneous celiac plexus block for the treatment of pancreatic pain. Ironically, little attention has been paid to celiac plexus block during laparotomy. We reviewed the cases of 12 patients with pancreatic carcinoma and severe abdominal pain who were treated surgically. All patients had operative celiac plexus block with absolute alcohol at the time of exploratory laparotomy for biliary bypass, gastroenterostomy, or tumor biopsy. Complete postoperative pain relief was obtained in 10 of the 12 patients; two had only partial relief. No operative complications were related to celiac plexus block; one patient died postoperatively of pneumonia. Average postoperative hospital stay was 13 days and average postoperative survival was 3 1/2 months. Most patients had excellent pain relief for at least 2 months or until death. Because most patients treated surgically for pancreatic carcinoma are receiving only palliation with biliary bypass or gastroenterostomy, surgeons should pay increased attention to pain relief. Operative celiac plexus block is easy, safe, and highly effective in relieving the agonizing pain of pancreatic carcinoma.