Pancreatic Cancer. Now for those patients
Now for those patients that can’t be resected, surgery still can give good palliation. The main problems that these patients have is jaundice, pain and sometimes gastric outlet obstruction. So palliative surgery would consist of a biliary decompression. Most surgeons will do an intraoperative celiac access block with absolute alcohol. The subject of gastric outlet bypass is controversial. Some surgeons will do this as a preventative measure but it carries its own morbidity. I think most surgeons would not do it unless gastric outlet obstruction was really threatened.
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Non-surgical decompression for the jaundice: there are two ways to do it. One is to insert a stent by ERCP. These are generally maintained longer, less subject to infection, but it is highly skill-dependent. You have to have a good endoscopist who has done a lot of ERCP’s to get a reliable result. Percutaneously at PTC you can pass a stent. It can usually be advanced through the lesion. This is complementary to ERCP because it sometimes can be done when ERCP fails, and vice-versa. Complication rate is higher with percutaneous stenting, mainly infections. There have been two studies now looking at the question of patients who present with severe jaundice but are thought to be operative candidates and are felt to be debilitated because of their jaundice. Would it be advantageous to stent them first before surgery, allow them to metabolically recover, and then do the surgery a week or two later? Both of those studies were negative. This is one series: complication rate of percutaneous stents over the life-span of the patient. About half of them were subject to some form of blockage or dysfunction. About one-third of the patients became septic, and about 5% required surgery for some complication of the stent.
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Radiotherapy is an effective modality for pain control in pancreatic cancer. Radiotherapy is the modality that is usually used for locally unresectability of the great vessels, is the most common reason, but still not metastasized distantly. It can even be used for pain control in someone with metastatic disease. Usually a patient with metastatic disease doesn’t have too much time to wait for their relief. There’s a small survival advantage for radiotherapy. That survival advantage is significantly improved by the dose, so you give a different dose for palliative purposes than you would for somebody who appears to be in good performance status. Three series in which chemo-radiotherapy was compared with radiotherapy for locally advanced pancreatic cancer. These patients all received full therapeutic doses of radiotherapy. Around 60 studies, prospective comparisons. And they show almost a 2:1 prolongation of survival with the addition of chemotherapy. At Jefferson, this is a comparison, basically drawing on the same patient population and it shows basically the same result. This is a study from Fox-Chase showing about what can be expected with full dose therapeutic radiotherapy and concurrent infusional chemotherapy to the tail, although these patients will probably eventually all die. But developing out around 15% at almost three years __(tape skipping). This is the randomized GITSG trial that was on the previous chart, in which they were looking at the question of whether chemotherapy added, randomized into three groups. One received what was considered to be the standard treatment, which was roughly 60 gray. The other group received the same 60 gray plus 5FU and did just about as well. And the 60 gray alone was definitely inferior.
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