Author : Bhadresh Bundela
Treatment of cancer of the pancras.
Where the patient has disease localised to the pancreas on scanning, then consideration to radical pancreatectomy should be given. Only radical surgical resection has a chance of cure and therefore this large operation must be therefore considered. In the operation called Whipple’s operation, the pancreas, duodenum and far end of stomach are removed, leaving a patent biliary tree draining into bowel. The patient is an insulin requiring diabetic following removal of the pancreas and requires pancreatic enzymal replacement The operation is a major undertaking and undoubtedly one for which results are better when the operator specialises in the procedure and performs a large number of these operations. Before the operation, the patient must be in the best possible condition and any jaundice may be best alleviated by a stent placed at endoscopic examination through the obstructed segment of the bile duct. The jaundice is then allowed to settle before the operation itself.
Even under these circumstances there is an operative mortality of up to 7% and the ultimate cure rate only 20-25% and this in this carefully selected, perceived better outlook, and localised cases. Unfortunately, the majority of patients (75% of the total) are not suitable for radical surgery as this disease often presents in too advanced a stage. Where the disease is still localised in the pancreatic region and has not yet invaded the liver on CT scanning, then there are some useful chemo-radiotherapy protocols which stand a reasonable chance of holding the disease at least for some time (the timing of the development of liver metastases being an unpredictable event that may not happen for some time in a significant minority of patients; it is for these that a chemo-radiotherapy programme will be of most use). The term chemo-radiotherapy is used for a course of therapy during which both chemotherapy drug treatment of cancer is delivered at the same time as a course of conventionally fractionated radiotherapy. Let us discuss each in turn: the chemotherapy drugs for this disease are not highly effective but can cause some worthwhile regressions and can delay the occurrence of liver disease, which, as implied before, is the potentially most lethal development in the natural history of this disease. The chemotherapy is usually given by intravenous injection once three weekly, although there are some interesting protocols with longer infusions of drugs during the radiotherapy course. The radiotherapy is the usual external beam therapy with high energy x-rays; the patient lies on the treatment couch and the beam is concentrated onto the pre-mapped area using a combination of approaches. Usually, the course of radiation therapy lasts several weeks; either the patient receives chemotherapy in the first and last weeks of the radiation, or, as stated above, there may be a continuous infusion during the course. The side effects of this therapy are nausea and languor which are difficult to fully control, but standard best anti-sickness drugs certainly help.
The results of this therapy can be well worthwhile in the group of patients who will not develop rapidly progressive liver metastases, but the overall outlook for life (prognosis in medical speak) remains suboptimal.
For patients presenting with metastatic disease, the use of combination chemotherapy may provide partial regressions for some time and are reasonably well tolerated in patients without severe jaundice at the time of presentation and not too wasted by the disease.
Sometimes an aggressive approach in patients with jaundice, by first stenting an obstructed biliary tree by the cancer can improve the patient's liver function and allow chemotherapy to be later instigated.
Recently, it has been demonstrated that the tyrosine kinase inhibitor: erlotinib (tarceva) adds to the benefit of chemotherapy in advanced disease.
Other forms of attack on liver metastases include thermo-ablation, a technique which seems effective at eliminating a small number liver metastases which are less than a couple of centimetres in diameter
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