Issues related to pancreatic cancer treatment
Pancreatic cancer is a tumor of the digestive system with a high degree of malignancy. It has an insidious onset, early metastasis and poor prognosis. In recent years, its incidence has been on the rise. According to Shanghai statistics, the incidence of pancreatic cancer is about 6/100,000, and the ratio of deaths to new cases is the highest among all malignant tumors, with high death rate and short survival period.
I. Diagnostic points Zhao Haiping, Department of General Surgery, Affiliated Hospital of Inner Mongolia Medical University
(I) Clinical manifestations
The clinical manifestation of pancreatic cancer is related to the site of pancreatic cancer mass and the scope of invasion. There is no obvious symptom in the early stage, but symptoms may appear when it develops to a certain extent. There may be anorexia, unexplained weight loss, abdominal discomfort or pain, new diabetes mellitus, thrombophlebitis, and mental symptoms such as anxiety, depression, insomnia, etc. Jaundice, enlarged gallbladder and gastrointestinal symptoms may also appear.
(II) Examination means
Including CA19-9 and other tumor markers, color ultrasound, CT, transendoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiography (MRCP), ultrasound endoscopy (EUS) and EUS or CT-guided fine-needle aspiration biopsy.
(III) TNM staging
1.TNM grading criteria
T
N
M
TX Primary tumor cannot be evaluated
NX Unable to assess regional lymph nodes
MX Unable to assess distant metastases
T0 No evidence of primary tumor
N0 No regional lymph node metastasis
M0 No distant metastasis
Tis carcinoma in situ
N1 with regional lymph node metastasis
M1 with distant metastasis
T1 Tumor is confined to the pancreas, ≤2cm
T2 Tumor confined to the pancreas, >2cm
T3 Tumor infiltrates outside the pancreas but does not involve the celiac trunk or superior mesenteric artery
T4 Tumor involving the celiac trunk or superior mesenteric artery (primary tumor cannot be removed)
2.Staging
Staging
T
N
M
Stage 0
Tis
N0
M0
Phase I A
T1
N0
M0
Phase ⅠB
T2
N0
M0
Phase IIA
T3
N0
M0
Phase IIB
T1~3
N1
M0
Phase III
T4
Any N
M0
Phase IV
Any T
Any N
M1
II. Treatment principles
If the lesion is limited and operable by examination, we should strive for a radical resection by dissection, and if necessary, surgery after neoadjuvant synchronous radiotherapy/chemotherapy after biopsy pathology confirmation. If the lesion cannot be resected, palliative surgery (bile duct decompression and drainage or gastrojejunostomy, etc.) is feasible, or stents can be placed to relieve jaundice obstruction and other symptoms, and postoperative chemotherapy and radiotherapy can be used as a comprehensive treatment.
In patients with limited lesions but no longer possible to perform exploratory surgery, i.e. locally advanced unresectable lesions, after biopsy pathology confirmation, patients in good general condition are treated with simultaneous chemotherapy/radiotherapy or chemotherapy alone (single agent or combination chemotherapy). Patients in poor general condition are treated with chemotherapy alone or best supportive care.
Patients with extensive lesions, systemic metastases or recurrence are treated with chemotherapy or best supportive care.
Adjuvant therapy after radical surgery includes concurrent chemotherapy/radiotherapy or chemotherapy alone. Regular follow-up is performed every 3 to 6 months for 2 years after surgery and annually thereafter. The follow-up includes symptoms, signs, tumor indicators and CT.
III. Treatment strategy
(I) Adjuvant chemotherapy for pancreatic cancer
A study by the Gastrointestinal Tract Cancer Study Group (GITSG) showed that patients who underwent adjuvant chemotherapy/radiotherapy after radical surgery had a median survival nearly two times longer than those who underwent surgery alone, with 2-year survival rates of 43% and 18%, and 5-year survival rates of 14% and 8%, respectively.
1. Fluorouracil regimen
Fluorouracil 600mg/m2 iv gtt (2h) d1~5
Repeat every 4 weeks.
2.Gicitabine regimen
Gemcitabine 1000mg/m2 iv gtt (30min) d1 d8 d15 (standard usage)
Repeat every 4 weeks.
Gemcitabine 1000 mg/m2 iv gtt [10 mg/(m2・min)] d1 d8 d15 (FDR usage)
Repeat once every 4 weeks.
(II) Chemotherapy for advanced pancreatic cancer
Advanced pancreatic cancer cannot be cured and is treated mainly with chemotherapy or best supportive care. The treatment plan is decided according to the previous treatment and the general condition of the patient itself. After the failure of first-line treatment, patients in good general condition can consider second-line treatment.
1.First-line treatment
(1) Fluorouracil regimen
Same as above
(2) Gemcitabine regimen
Same as above
(3) Gemcitabine+capecitabine regimen
Gemcitabine 1000 mg/m2 iv gtt (30min) d1 d8 d15
Capecitabine (Xeloda) 650 mg/m2 bid po d1~14
Repeat every 3 weeks
(4) Gemcitabine + oxaliplatin regimen
Gemcitabine 1000 mg/m2 iv gtt [10 mg/(m2・min)] d1
Oxaliplatin 100 mg/m2 iv gtt (2h) d1
Repeat every 2 weeks
(5) Gemcitabine + cisplatin regimen
Gemcitabine 1000 mg/m2 iv gtt [10 mg/(m2・min)] d1
Cisplatin 50 mg/m2 iv gtt d1
Repeat every 2 weeks
(6) Gemcitabine + erlotinib regimen
Gemcitabine 1000 mg/m2 iv gtt (30min)
Once a week for 7 weeks with 1 week off, then once a week for 3 weeks with 1 week off, repeated every 4 weeks
Erlotinib 100mg po qd
2.Second-line treatment
(1) Capecitabine monotherapy regimen
Capecitabine (Xiloda) 1000 mg/m2 bid po d1~14
Repeat every 3 weeks
(2) Fluorouracil+oxaliplatin regimen
Oxaliplatin 85 mg/m2 iv gtt (2h) d8 d22
Calcium folinic acid 200 mg/m2 iv gtt (2h) d1 d8 d15 d22
Fluorouracil 2000 mg/m2 iv gtt (24h continuous) d1 d8 d15 d22
Repeat every 6 weeks.
(3) FDR use in combination with oxaliplatin may be effective if standard gemcitabine use is ineffective.