ADENOCARCINOMA OF THE PANCREAS - RECENT CONTROVERSIES, CURRENT MANAGEMENT, AND FUTURE THERAPIES

Pancreatic cancer is the fourth leading cause of adult cancer mortalit y. The etiology of cancer of the pancreas remains a mystery despite th e implication of various agents such as coffee, alcohol and cigarettes . Adenocarcinoma of the pancreas most commonly occurs in the pancreati c head where symptomatic jaudice or gastric outlet obstruction may cau se the patient to seek medical care when the tumor is localized to the pancreas. In contrast, adenocarcinoma of the pancreatic body or tail is characterized by clinically silent growth, resulting in an advanced clinical stage at the time of diagnosis. Rational anticancer therapy for patients with adenocarcinoma of the pancreatic head is based upon an accurate knowledge of the natural history and patterns of treatment failure. Patients who undergo surgical resection for adenocarcinoma o f the pancreatic head have a long-term survival rate of only 13-25%(1- 6) and a median survival of 12-24 months.(7-10) Disease recurrence is common: local recurrence: occurs in up to 90% of patients,(11-15) live r metastases in 50-70% of patients,(8,9,12,16) and peri-toned recurren ce (abdominal carcinomatosis) in approximately 50% of patients.(17) Su ch modest survivals in patients with localized, early stage disease, c ombined with the potential morbidity and lengthy recovery period assoc iated with pancreaticoduodenectomy, have resulted in confusion on the part trf physicians regarding the appropriate use of surgery, both for curative resection and palliation. The current management of patients with pancreatic cancer at our institution involves: 1) a selective ap proach to the use of laparotomy based on the use of accurate radiograp hic imaging techniques, and the availability of reliable minimally inv asive techniques for biliary decompression, 2) the use of multimodalit y therapy in all patients with localized, potentially resectable disea se, and 3) a standardized approach to surgery and perioperative patien t management. The goals of this approach are to maximize length and qu ality of patient survival while minimizing treatment-related toxicity and limiting the social and economic impact of complicated, multimodal ity therapy. The data in support of such an approach will ire reviewed along with recent developments in the ongoing quest for effective sys temic therapy.