Management of Pancreatic Cancer

Jul 14, 2024

ISG Master Class: Management of Pancreatic Cancer

Moderators and Panelists:

  • Dr. Gian Ramesh: Head of Gastroenterology at The Astor Medicity, Kochi
  • Dr. Shelly Shri Khande: Professor of Surgery at Tata Memorial Hospital, Mumbai
  • Dr. Raju Sharma: Professor of Radiology at AIIMS
  • Dr. Akash Shah: Professor of Medical Oncology
  • Professor Sudeep

Key Points:

Overview

  • 3rd session on GI oncology, focusing on pancreatic cancer.
  • Pancreatic cancer is challenging due to diverse presentations, difficulty in early detection, and aggressive spread.
  • Importance of multi-modal management involving surgery, radiology, oncology, and gastroenterology.

Imaging and Diagnosis:

Contrast-Enhanced CT (Primary Modality):

  • Essential for detection, characterization, and staging of tumors.
  • Pancreatic phase at 45 seconds & portal venous phase at 70 seconds from injection.
  • Primary for distinguishing between inflammatory masses and neoplastic masses.

MRI (Problem-solving Role):

  • Useful for iso-dense masses not visible on CT.
  • MRCP helpful for visualization of ductal structures.
  • Identifies small liver lesions and peritoneal metastases.

Endoscopic Ultrasound (EUS):

  • Provides incremental information for indeterminate lesions on CT.
  • High sensitivity for small tumors (<2 cm) and better assessment of vascular invasion.

Tumor Characteristics on Imaging:

  • Hypovascular appearance on CT; use of pancreatic protocol essential.
  • Hypo-enhancing lesion detection in pancreatic phase.
  • Use of diffusion-weighted imaging (DWI) in MR for small liver lesions.
  • Common imaging features: ductal obstruction, double duct sign, teardrop deformity.

Staging:

  • Accurate staging essential for treatment planning, mainly using NCCN guidelines.
  • Stages: Resectable, Borderline-Resectable, Locally Advanced, and Unresectable.
  • Tumor-Vessel Contact used for defining stages – Resectability determined by the contact with SMA, SMV, etc.
  • Utilizes imaging techniques (CT, MR, EUS) for detailed analysis.

Tissue Acquisition:

  • Not always necessary for resectable tumors based on imaging and clinical suspicion.
  • Essential for atypical masses, planned neoadjuvant chemotherapy, or palliative care.
  • EUS-guided fine-needle aspiration (FNA) preferred over percutaneous FNA.

Surgery:

  • Criteria for pancreatic surgical resection based on resectability and vascular involvement.
  • Radical resection without preoperative biopsy when solid pancreatic head mass suspected as adenocarcinoma.
  • Welcomes input from multi-disciplinary teams for borderline resectable and locally advanced cases.
  • Key surgical interventions: Whipple procedure, pancreatectomy with vascular reconstruction.
  • Surgeons require quality imaging for pre-op planning and intra-op decision-making.

Neoadjuvant and Adjuvant Therapy:

  • Neoadjuvant therapy recommended for borderline resectable cases to improve surgical outcomes.
  • Multiple regimens (FOLFIRINOX, gemcitabine) discussed based on performance status and response.
  • Adjuvant chemotherapy shown to improve survival in resectable cases, increasing 5-year survival to 30-40%.

Palliative Care:

  • Ensuring quality of life through effective palliative chemotherapies and supportive care.
  • Focus on symptom management, particularly for unresectable cases.
  • Consideration of expandable metal stents for longer biliary drainage.

Screening and Monitoring:

  • CA 19-9 marker used pre/post-treatment for diagnosis and monitoring.
  • Follow-up imaging (CT, MR) necessary post-treatment to assess for recurrence.
  • Ongoing research in AI and new markers for pancreatic cancer screening and diagnosis.

Conclusion:

  • Pancreatic cancer management requires a comprehensive, multi-disciplinary approach.
  • Advances in Imaging, surgery, and chemotherapy are enhancing patient outcomes.
  • Early and accurate diagnosis, optimal use of neoadjuvant therapies, and multidisciplinary teamwork are crucial.

Note: This lecture emphasizes the importance of care coordination between gastroenterologists, surgeons, radiologists, and oncologists to provide the best care options for pancreatic cancer patients.