Symptoms and Diagnosis
More than 90% of patients with pancreatic cancer present with pain, jaundice, and/or weight loss. Acute pancreatitis or recent onset of diabetes mellitus may occasionally be the initial presentation. Vague upper abdominal symptoms may precede the onset of jaundice or overt pain by months and illustrate the difficulty of early diagnosis in this disease. Whenever pancreatic cancer is suspected, a computed tomography (CT) scan of the upper abdomen should be obtained. If a mass is not seen, but clinical suspicion remains high, endoscopic ultrasound or endoscopic retrograde pancreatography (ERCP) may be indicated. It should be noted that a normal endoscopic ultrasound does not rule out the presence of a tumor. A normal pancreatic ductogram will exclude a carcinoma in the main duct but may miss small branch duct neoplasms. Most importantly, routine ERCP for diagnostic purposes may be associated with unnecessary morbidity.
Staging
Preoperative staging in pancreatic cancer is used to determine if a patient has a resectable tumor, a localized but unresectable tumor, or metastatic disease. Contemporary staging utilizes multidetector or multislice CT scanning with intravenous contrast to determine the presence or absence of metastatic disease, vascular invasion (often precluding resection), and variations in arterial anatomy. Endoscopic ultrasonography may be helpful in assessing vascular involvement, local nodal metastasis, or extrapancreatic tumor extension, and adds the dimension of transduodenal fine-needle aspiration to confirm the diagnosis cytologically, which is important if resection is not feasible and chemotherapy or chemoradiation is planned. Laparoscopy may be useful in identifying small metastatic hepatic and/or peritoneal implants, in which case further surgery may be avoided. Surgeons with experience in pancreatic surgery should evaluate all patients with pancreatic carcinoma to ascertain their candidacy for resection unless they clearly have distant metastatic disease.
Treatment
In North America, less than one in five patients will have resectable tumors. Tumors in the head of the pancreas are treated by pancreaticoduodenectomy, with or without preservation of the pylorus. Preoperative or intraoperative histologic evidence of malignancy is not required to carry out resection in experienced hands. While a distal pancreatectomy with splenectomy is the procedure of choice for tumors of the body or tail of the pancreas, it is only possible in about 1 in 20 patients. Adjuvant therapy should be considered in all patients following surgery for pancreatic adenocarcinoma. We encourage all physicians to support available clinical trials and encourage all eligible patients to consider protocol-based therapy.
For the majority of patients with unresectable tumors, treatment is primarily one of palliation. In patients with jaundice and gastric outlet obstruction, biliary and/or gastric bypass is indicated. At the time of surgery, a celiac plexus block with 50% alcohol may prevent or relieve pain. In the presence of jaundice alone, treatment is determined by the availability of resources. An endoscopic stent is as effective as surgical bypass, with slightly less morbidity and expense. Patients with locally advanced or metastatic disease and acceptable performance status should be considered for protocol-based therapy. In the absence of an available clinical trial, gemcitabine (alone or in combination) is the evolving standard treatment. Patients with locally advanced disease, especially those with pain as a major symptom, may benefit from chemoradiation (capecitabine-based chemoradiation).
Qualifications
At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform operations for pancreatic cancer. These surgeons have successfully completed at least 5 years of surgical training after medical school graduation and are qualified to perform operations on the pancreas. Pancreatic surgery should preferably be performed by surgeons with special knowledge, training, and experience in the management of pancreatic disease. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive surgery of the pancreas is important to assess. The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes.
