1. Pancreatic Cancer

2. Pancreatic Cancer Case Case presentation 67 year old male Unremarkable previous medical history No family history of pancreatic cancer or other tumour syndromes Heavy smokers (>15 per day for more than 40 year) Obstructive jaundice, bili 378 CT: mass lesion in pancreatic head. No signs of vascular involvement or metastases

3. Pancreatic Cancer Case Question 1 1) send patient direct for Whipple’s surgery 2) before considering surgery first do ERCP to image stricture en drain the biliary tree What would you do?

4. Pancreatic Cancer Case Question 1 Direct surgery is not inferior to PBD 1 rate of surgical complications are is not lowered after PBD high rate of stent related complications PDB adds substantially to the overall costs 1 N Engl J Med. 2010 Jan 14;362(2):129-37

5. Pancreatic Cancer Case Question 2 1) yes, to confirm the presence of the lesion and non involvement of the vessels 2) yes, to confirm diagnosis by means of fine needle aspiration 3) no, has no added value to CT scan Would you consider EUS?

6. Pancreatic Cancer Case Question 2; background information Series dealing with imaging are largely retrospective or small cohort series Importantly, most studies are already dated and do no justice to CT and MR advancements in recent years EUS is probably still the most sensitive modality tot detect small lesions (< 2 cm) Differential diagnosis? Elastography? Contrast-enhanced?

7. Pancreatic Cancer Case Question 3 1) always surgery with vascular resection and portal vein reconstruction unless full circumferential involvement and narrowing 2) depends on the extent of involvement 3) do EUS to confirm involvement and then deny resection 4) surgery is not indicated; palliative treatment If CT shows a relationship with the portal vein. Would you still consider surgery?

8. Pancreatic Cancer Case Question 3 1 J Gastrointest Surg. 2010 : ahead of publ. Systematic review of 28 retrospective studies (1458 patients) Vein thrombosis or arterial involvement reported as contraindications to surgery in 62% and 71% of studies Median mortality rate 4% (0 to 17%) Median R0 and R1 rates were 75% (14% to 100%) and 25% (0% to 86%)

9. Pancreatic Cancer Case Question 3 1 J Gastrointest Surg. 2010 : ahead of publ. Nine of 10 (90%) studies comparing survival after extended pancreaticoduodenectomy with vascular resection versus standard pancreaticoduodenectomy reported statistically similar (p > 0.05) survival outcomes Overall, vascular resection was not associated with a poorer survival.

10. Pancreatic Cancer Case Question 4 1) still resect the tumour; this is the best palliation 2) perform a gastrojejunostomy and hepaticojejunostomy 3) Only perform a gastrojejunotomy 4) Close the abdomen and deal with biliary and gastric outlet obstruction endoscopically If it turns out that the tumour can not be resected radically at exploration, what would you do?

11. Pancreatic Cancer Case Question 4 Br J Surg 2009: 96; 711-9 Systematic review and meta-analysis of prophylactic gastrostomy for unresectable cancer 3 prospective comparative studies chance of gastric outlet obstruction during follow-up was significantly lower (OR 0.06, 95% CI 0.02 to 0.21) No increased morbidity of mortatlity at the expense of 3 days longer hospital admission No such data available for prophylactic biliary bypass surgery

12. Pancreatic Cancer Case Question 4 1 Gastrointest Endosc 2010 : 71; 490-499 In case of symptomatic gastric outlet obstruction in palliative patients there very few prospective and/or randomized data Small randomized trial 19 patients GJJ and 21 stent placement 1 more rapid improvement of food intake after stent more re-interventions after stent long-term relief better after GJJ (GOOSS score > or = 2, 72 days versus 50 days) Recommendation: Stent if suspected survival is less then 2 months

13. Pancreatic Cancer Case Question 5 1) Always place a plastic stent 2) Always place a metal stent 3) Metal only in case of fast occlusion of plastic stent or expected long survival 4) Surgical bypass in cases with expected long survival How do you deal with a malignant biliary obstruction in unresectable pancreatic cancer?

14. Pancreatic Cancer Case Question 5 Answer largely depends on which perspective one chooses Patency rates of metal stents are undoubtedly superior to plastic stents From a cost perspective POV the use of metal stents is depended on patient survival (>3 months(?)) unit cost of additional ERCP at institution (>$1820) 1 Preventing cholangitic complication may prove to be of more importance if palliative chemotherapy is given at a higher rate to patients 1 Eur J Gastroenterol 2007: 19; 1041-2

15. Pancreatic Cancer Case Question 6 1) No, there is no scientific proof for its efficacy 2) No, it may increase QoL to some extent, but to me this doe not justifies its use 3) Yes, there is enough scientific proof of efficacy to justify its routine use Do you offer patients with unresectable pancreatic cancer (palliative) chemotherapy?

16. Pancreatic Cancer Case Question 6 J Clin Oncol 2007: 25; 2607-15 Cochrane Database Syst Rev 2006:3 World J Gastroenterol 2007: 13; 224-7 Two high quality systematic reviews comparing best supportive care to chemotherapy in advanced pancreatic cancer. Overall survival was significantly better One-year mortality was significantly reduced However, unfit patients with a poor Karnosfsky status (<70%) have only marginal benefit from chemotherapy and may often benefit more from optimal supportive care