n e w e ng l a n d j o u r na l
m e dic i n e
Manuel Hidalgo, M.D. eaths from pancreatic ductal adenocarcinoma, also known as pancreatic cancer, rank fourth among cancer-related deaths in the United States. In 2008, the estimated incidence of pancreatic cancer in the United States was 37,700 cases, and an estimated 34,300patients died from the disease.1 Pancreatic cancer is more common in elderly persons than in younger persons, and less than 20% of patients present with localized, potentially curable tumors. The overall 5-year survival rate among patients with pancreatic cancer is 2 cm in longest dimension Tumor extends beyond the pancreas but does not involve the celiac axis or superior mesenteric artery Regionallymphnode metastasis Tumor involves the celiac axis or the superior mesenteric artery (unresectable disease) Distant metastasis Characteristics
* N denotes regional lymph nodes, M distant metastases, and T primary tumor. † Data are from Bilimoria et al.45
splenic veins are classified as T3, since these tients who are treated with neoadjuvant therapy veins can be resected and reconstructed,provid- before resection or who are referred to other centers for treatment.52 Patients with symptoms ed that they are patent. of cholangitis require decompression as well as antibiotic treatment before surgery. M a nagemen t of E a r ly Dise a se Even if the tumor is fully resected, the outPatients with pancreatic cancer are best cared for come in patients with early pancreatic cancer is bymultidisciplinary teams that include surgeons, disappointing. The results of three large ranmedical and radiation oncologists, radiologists, domized clinical trials, summarized in Table 2 in gastroenterologists, nutritionists, and pain spe- the Supplementary Appendix, have established cialists, among others.46,47 For patients with resec- the role of postoperative treatment in patients table disease,surgery remains the treatment of with resected pancreatic cancer.53-55 The results choice.48 Depending on the location of the tumor, of the European Study Group for Pancreatic Canthe operative procedures may involve cephalic cer Trial 1 and Charité Onkologie 1 trial show that pancreatoduodenectomy (the Whipple procedure), postoperative administration of chemotherapy distal pancreatectomy, or totalpancreatectomy. with either fluorouracil and leucovorin or gemA minimum of 12 to 15 lymph nodes should be citabine, a nucleotide analogue commonly used resected, and every attempt should be made to to treat advanced pancreatic cancer, improves obtain a tumor-free margin. Data from several progression-free and overall survival. In addirandomized clinical trials indicate that a more tion, theRadiation Therapy Oncology Group extensive resection does not improve survival but trial 97-04 showed that the combination of gemincreases postoperative morbidity. Recent studies citabine with fluorouracil administered as a show that the results of vein resection and vascu- continuous infusion and radiation therapy relar reconstruction in patients with limited in- sulted in a trend toward increasedoverall survival, volvement of the superior mesenteric vein and although the increase was not significant, among portal vein are similar to the results in patients patients with tumors in the head of the pancreas. without vein involvement.49 Poor prognostic fac- These results are similar to those of large singletors include lymph-node metastases, a high tumor institution series that incorporatedradiation grade, a large tumor, high levels of CA 19-9, per- therapy.56 sistently elevated postoperative levels of CA 19-9, Notwithstanding differences in patient popuand positive margins of resection.38,40,50,51 lations and therapies, the outcome in patients Up to 70% of patients with pancreatic cancer treated in these trials was similar, with a median present with biliary obstruction, which can be...