PANCREATIC-CARCINOMA THERAPEUTIC STRATEGI ES

Surgery: Surgery whether curative or palliative, is the major modality of treatment. A complete resection is possible in about 20% of patien ts with a median survival of 12 to 16 months and a 20% five year survi val. After complete resection 70 to 80% of patients develop a local re currence. Biliary and gastro-intestinal bypasses as well as antalgic t echniques are useful palliative procedures. Adjuvant and neoadjuvant t reatment: Chemoradiotherapy is used either as adjuvant or neoadjuvant treat ment. External beam irradiation techniques are used to deliver 4 5 to 50 Gy to the pancreas in five to six weeks. Concomitant fluoroura cil is administered in bolus injections or better in continuous infusi on, either alone or in association with cisplatinum. Chemoradiotherapy reduces the local relapse rate and slightly though significantly, inc reases the median survival. Therefore, after chemoradiotherapy, metast atic spread becomes the major cause of death. Palliative treatment: Fo r locally advanced diseases, chemoradiotherapy has a true palliative e ffect with acceptable toxicity. Metastatic disease remains a challenge . Fluorouracil based chemotherapy with or without cisplatinum occasion ally obtains effective palliation. Among new agents, only gemcitabine has proven clinical activity associated with low toxicity and is pract ical to use. Therapeutic strategy: Presently, patients with resectable pancreatic carcinoma should be included in a prospective trial to rec eive combined modality treatment with adjuvant or neo-adjuvant chemora diotherapy. The choice of treatment for patients with locally advanced or metastatic disease, should be based on the possibility of assuring a satisfactory quality of life. Present research should progress thro ugh controlled clinical trials to study original systemic treat ment a nd combined modalities able to produce a lasting local control.