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Surgical Bypass versus Endoscopic Stenting for Unresectable Head Pancreatic Cancer, Which Palliative Treatment Is Better in Developing Countries, Morocco as an Example  [PDF]
Khalid Mazine, Hamdaoui Mohammed, El Ghazi Karima, Ousadden Abdelmalek, Mazaz Khalid, Ibrahimi Adil, Ait Taleb Khalid, Benajeh Dafrallah, Benjelloun Elbachir
Open Journal of Gastroenterology (OJGas) , 2017, DOI: 10.4236/ojgas.2017.75017
Abstract: Background: Metal stents for unresectable pancreatic cancer are associated with longer patency and superior cost-effectiveness. However, they are too expensive to be recommended routinely in developing countries. Moreover, a debate on outcome results in these patients who receive plastic biliary endoprothesis versus surgical bypass as palliation of obstructive jaundice. We aimed to compare retrospectively the outcomes in patients treated with plastic stent or surgical bypass as a palliative option for these patients. Patients and Methods: We have examined data for patients (n = 86) who received endoscopic stenting (n = 64) or surgical bypass (n = 22), from January 2013 to November 2016, as a palliative treatment for obstructive jaundice from inoperable cancer head pancreas. Results: Serum bilirubin and CA19.9 levels were comparable in age and gender matched patient groups. Moreover, post-operative major complications and 30-days mortality showed no significant differences among patient groups. However, surgical bypass treated patients showed longer initial hospital stay (9 vs. 6 days, p = 0.014), higher cost ($1600 vs. $1088) and longer survival (192 vs. 101 days, p = 0.003) compared to endoscopy-stenting treated patients. Re-hospitalization was required for 5 stented patients (averaged $448). Conclusion: Biliary bypass surgery for unresectable pancreatic cancer may improve patient survival, although prolongs hospital stay. It may be recommended for relatively fit patients with a life expectancy of 6 months and more.
Safety and Efficacy of Radiofrequency Ablation in the Management of Unresectable Bile Duct and Pancreatic Cancer: A Novel Palliation Technique  [PDF]
Paola Figueroa-Barojas,Mihir R. Bakhru,Nagy A. Habib,Kristi Ellen,Jennifer Millman,Armeen Jamal-Kabani,Monica Gaidhane,Michel Kahaleh
Journal of Oncology , 2013, DOI: 10.1155/2013/910897
Abstract: Objectives. Radiofrequency ablation (RFA) has replaced photodynamic therapy for premalignant and malignant lesions of the esophagus. However, there is limited experience in the bile duct. The objective of this pilot study was to assess the safety and efficacy of RFA in malignant biliary strictures. Methods: Twenty patients with unresectable malignant biliary strictures underwent RFA with stenting between June 2010 and July 2012. Diameters of the stricture before and after RFA, immediate and 30 day complications and stent patency were recorded prospectively. Results. A total of 25 strictures were treated. Mean stricture length treated was 15.2?mm (SD = 8.7?mm, Range = 3.5–33?mm). Mean stricture diameter before RFA was 1.7?mm (SD = 0.9?mm, Range = 0.5–3.4?mm) while the mean diameter after RFA was 5.2?mm (SD = 2?mm, Range = 2.6–9?mm). There was a significant increase of 3.5?mm (t = 10.8, DF = 24, P value = <.0001) in the bile duct diameter post RFA. Five patients presented with pain after the procedure, but only one developed mild post-ERCP pancreatitis and cholecystitis. Conclusions: Radiofrequency ablation can be a safe palliation option for unresectable malignant biliary strictures. A multicenter randomized controlled trial is required to confirm the long term benefits of RFA and stenting compared to stenting alone. 1. Introduction Self-expanding metal stents (SEMS) have become the mainstay palliative treatment for malignant biliary obstruction in patients with a life expectancy greater than 3 months [1, 2]. Their use has improved bile duct patency beyond what was achieved with plastic stents; however, long-term patency continues to be an unresolved issue. SEMS can occlude from tissue ingrowth or overgrowth, benign epithelial hyperplasia or secondary to biofilm, and sludge formation within the lumen of the stent [3]. Up to 50% of patients will have stent occlusion in the first 6 to 8 months [4, 5]. Different design alternatives have been explored in an attempt to improve stent patency. Covered SEMS were designed to prevent tissue ingrowth; however, they are contra-indicated for hilar drainage, have higher migration rates, and might be associated with increased risks of pancreatitis and cholecystitis [6–11]. Another treatment strategy to prolong stent patency and eventual survival is photodynamic therapy (PDT). PDT showed promising results; however, it carries a high complication rate including cholangitis and photosensitivity requiring the patient to avoid direct exposure to light for 4–6 weeks [12–14]. Radiofrequency ablation (RFA) has been used for
Endoscopic Palliation for Pancreatic Cancer  [PDF]
Mihir Bakhru,Bezawit Tekola,Michel Kahaleh
Cancers , 2011, DOI: 10.3390/cancers3021947
Abstract: Pancreatic cancer is devastating due to its poor prognosis. Patients require a multidisciplinary approach to guide available options, mostly palliative because of advanced disease at presentation. Palliation including relief of biliary obstruction, gastric outlet obstruction, and cancer-related pain has become the focus in patients whose cancer is determined to be unresectable. Endoscopic stenting for biliary obstruction is an option for drainage to avoid the complications including jaundice, pruritus, infection, liver dysfunction and eventually failure. Enteral stents can relieve gastric obstruction and allow patients to resume oral intake. Pain is difficult to treat in cancer patients and endoscopic procedures such as pancreatic stenting and celiac plexus neurolysis can provide relief. The objective of endoscopic palliation is to primarily address symptoms as well improve quality of life.
Multimodality treatment of unresectable hepatic metastases from pancreatic glucagonoma  [cached]
Guido Poggi,Laura Villani,Giovanni Bernardo
Rare Tumors , 2009, DOI: 10.4081/rt.2009.e6
Abstract: Glucagonomas are pancreatic islet cell tumors arising from the alpha cells which belong to neuroendocrine tumors. They frequently metastasize to the liver. We report the case of a 52- year old man with a pancreatic glucagonoma with synchronous multiple liver metastases treated by surgery, transarterial chemoembolization, percutaneous radiofrequency thermal ablation and long-acting octreotide. Our report confirms that a multimodal approach is very effective in patients with unresectable liver metastases from pancreatic endocrine tumors providing long-lasting palliation and probably prolonging survival.
Palliative Interventional and Surgical Therapy for Unresectable Pancreatic Cancer  [PDF]
Volker Assfalg,Norbert Hüser,Christoph Michalski,Sonja Gillen,Jorg Kleeff,Helmut Friess
Cancers , 2011, DOI: 10.3390/cancers3010652
Abstract: Palliative treatment concepts are considered in patients with non-curatively resectable and/or metastasized pancreatic cancer. However, patients without metastases, but presented with marginally resectable or locally non-resectable tumors should not be treated by a palliative therapeutic approach. These patients should be enrolled in neoadjuvant radiochemotherapy trials because a potentially curative resection can be achieved in approximately one-third of them after finishing treatment and restaging. Within the scope of best possible palliative care, resection of the primary cancer together with excision of metastases represents a therapeutic option to be contemplated in selected cases. Comprehensive palliative therapy is based on treatment of bile duct or duodenal obstruction for certain locally unresectable or metastasized advanced pancreatic cancer. However, endoscopic or percutaneous stenting procedures and surgical bypass provide safe and highly effective therapeutic alternatives. In case of operative drainage of the biliary tract (biliodigestive anastomosis), the prophylactic creation of a gastro-intestinal bypass (double bypass) is recommended. The decision to perform a surgical versus an endoscopic procedure for palliation depends to a great extent on the tumor stage and the estimated prognosis, and should be determined by an interdisciplinary team for each patient individually.
Advances in diagnosis, treatment and palliation of pancreatic carcinoma: 1990-2010  [cached]
Chakshu Sharma,Karim M Eltawil,Paul D Renfrew,Mark J Walsh
World Journal of Gastroenterology , 2011,
Abstract: Several advances in genetics, diagnosis and palliation of pancreatic cancer (PC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. PC is relatively common as it is the fourth leading cause of cancer related mortality. Most patients present with obstructive jaundice, epigastric or back pain, weight loss and anorexia. Despite improvements in diagnostic modalities, the majority of cases are still detected in advanced stages. The only curative treatment for PC remains surgical resection. No more than 20% of patients are candidates for surgery at the time of diagnosis and survival remains quite poor as adjuvant therapies are not very effective. A small percentage of patients with borderline non-resectable PC might benefit from neo-adjuvant chemoradiation therapy enabling them to undergo resection; however, randomized controlled studies are needed to prove the benefits of this strategy. Patients with unresectable PC benefit from palliative interventions such as biliary decompression and celiac plexus block. Further clinical trials to evaluate new chemo and radiation protocols as well as identification of genetic markers for PC are needed to improve the overall survival of patients affected by PC, as the current overall 5-year survival rate of patients affected by PC is still less than 5%. The aim of this article is to review the most recent high quality literature on this topic.
Intraoperative radiofrequency ablation combined with iodine seed implantation for unresectable pancreatic cancer  [cached]
Yi-Ping Zou, Wei-Min Li, Fang Zheng, Fu-Cheng Li, Hui Huang, Ji-Dong Du, Hao-Run Liu
World Journal of Gastroenterology , 2010,
Abstract: AIM: To evaluate the feasibility, efficacy and safety of intraoperative radiofrequency ablation (RFA) combined with 125iodine seed implantation for unresectable pancreatic cancer.METHODS: Thirty-two patients (21 males and 11 females) at the age of 68 years (range 48-90 years) with unresectable locally advanced pancreatic cancer admitted to our hospital from January 2006 to May 2008 were enrolled in this study. The tumor, 4-12 cm in diameter, located in pancreatic head of 23 patients and in pancreatic body and tail of 9 patients, was found to be unresectable during operation. Diagnosis of pancreatic cancer was made through intraoperative biopsy. Patients were treated with FRA combined with 125iodine seed implantation. In brief, a RFA needle was placed, which was confirmed by intraoperative ultrasound to decrease the potential injury of surrounding vital structures, a 125iodine seed was implanted near the blood vessels and around the tumor border followed by bypass palliative procedure (cholangio-jejunostomy and/or gastrojejunostomy) in 29 patients.RESULTS: The serum CA 19-9 level was decreased from 512 ± 86 U/mL before operation to 176 ± 64 U/mL, 108 ± 42 U/mL and 114 ± 48 U/mL, respectively, 1, 3 and 6 mo after operation (P < 0.05). The pain score on day 7 after operation, 1 and 3 mo after combined therapy was decreased from 5.86 ± 1.92 before operation to 2.65 ± 1.04, 1.65 ± 0.88 and 2.03 ± 1.16, respectively, after operation (P < 0.05). The rate of complete response (CR), partial response (PR), stable disease (SD), progressive disease (PD) in 32 patients was 21.8% (7/32), 56.3% (18/32), 15.6% (5/32) and 6.3% (2/32), respectively, 6 mo after operation, with a median overall survival time of 17. 5 mo. The median survival time of patients at stage III was longer than that of those at stage IV (19 mo vs 10 mo, P = 0.0026). The median survival time of patients who received and did not receive chemotherapy after operation was 20 mo and 16 mo, respectively (P = 0.0176). Of the 32 patients, 3 (10.6%) experienced postoperative complications including transient biliary leaks in 2 patients and acute pancreatitis in 1 patient. All the patients recovered well after conservative support treatment.CONCLUSION: Intraoperative RFA combined with 125iodine seed implantation is a feasible and safe procedure for unresectable pancreatic cancer with acceptable minor complications, and can prolong the survival time of patients, especially those at stage III.
Intraoperative ultrasound-guided iodine-125 seed implantation for unresectable pancreatic carcinoma
Junjie Wang, Yuliang Jiang, Jinna Li, Suqing Tian, Weiqiang Ran, Dianrong Xiu
Journal of Experimental & Clinical Cancer Research , 2009, DOI: 10.1186/1756-9966-28-88
Abstract: Fourteen patients with pancreatic carcinoma that underwent laparotomy and considered unresectable were included in this study. Nine patients were pathologically diagnosed with Stage II disease, five patients with Stage III disease. Fourteen patients were treated with 125I seed implantation guided by intraoperative ultrasound and received D90 of 125I seeds ranging from 60 to 140 Gy with a median of 120 Gy. Five patients received an additional 35–50 Gy from external beam radiotherapy after seed implantation and six patients received 2–6 cycles of chemotherapy.87.5% (7/8) of patients received partial to complete pain relief. The response rate of tumor was 78.6%, One-, two-and three-year survival rates were 33.9% and 16.9%, 7.8%, with local control of disease achieved in 78.6% (11/14), and the median survival was 10 months (95% CI: 7.7–12.3).There were no deaths related to 125I seed implant. In this preliminary investigation, 125I seed implant provided excellent palliation of pain relief, local control and prolong the survival of patients with stage II and III disease to some extent.The incidence of pancreatic carcinoma has increased in recent decades, yet the treatment outcome for this disease remains unsatisfactory. Despite the introduction of new therapeutic techniques combined with aggressive modalities, such as external beam radiotherapy (EBRT) and chemotherapy, the prognosis of pancreatic carcinoma remained to be very poor, with a mortality rate of more than 90% [1]. Only 15% to 20% of patients with pancreatic carcinoma are suitable for resection, and even with resection, long term survival still remains poor [2,3]. Most of pancreatic carcinoma was diagnosed in the locally advanced or metastatic stage, and the median survival rate was approximately 6 months with palliative treatment. Biliary and gastric bypass have been used for palliation in unresectable pancreatic carcinomas and median survival in these patients was often 5–6 months [4,5].More recently, EBRT and
En Masse Resection of Pancreas, Spleen, Celiac Axis, Stomach, Kidney, Adrenal, and Colon for Invasive Pancreatic Corpus and Tail Tumor  [PDF]
Koray Kutluturk,Abdul Hamid Alam,Cuneyt Kayaalp,Emrah Otan,Cemalettin Aydin
Case Reports in Surgery , 2013, DOI: 10.1155/2013/376035
Abstract: Providing a more comfortable life and a longer survival for pancreatic corpus/tail tumors without metastasis depends on the complete resection. Recently, distal pancreatectomy with celiac axis resection was reported as a feasible and favorable method in selected pancreatic corpus/tail tumors which had invaded the celiac axis. Additional organ resections to the celiac axis were rarely required, and when necessary it was included only a single extra organ resection such as adrenal or intestine. Here, we described a distal pancreatic tumor invading most of the neighboring organs—stomach, celiac axis, left renal vein, left adrenal gland, and splenic flexure were treated by en bloc resection of all these organs. The patient was a 60-year-old man without any severe medical comorbidities. Postoperative course of the patient was uneventful, and he was discharged on postoperative day eight without any complication. Histopathology and stage of the tumor were adenocarcinoma and T4 N1 M0, respectively. Preoperative back pain of the patient was completely relieved in the postoperative period. As a result, celiac axis resection for pancreatic cancer is an extensive surgery, and a combined en masse resection of the invaded neighboring organs is a more extensive surgery than the celiac axis resection alone. This more extensive surgery is safe and feasible for selected patients with pancreatic cancer. 1. Introduction Unlike pancreatic head tumors, distal pancreas tumors rarely cause jaundice. Mostly these lesions cause upper abdominal pain radiating to the low back as a result of local invasion to the celiac axis. Left-sided pancreatic tumors are usually delayed in diagnosis because of the difficulties at the differential diagnosis of low back pain which is very frequent in elderly people. Therefore, liver metastasis, peritoneal carcinomatosis, or major vascular invasion to celiac axis or superior mesenteric artery is frequent at the time of diagnosis and up to 75% of the tumors are evaluated as unresectable [1–6]. Providing a more comfortable life and a longer survival for pancreatic corpus/tail tumors without metastasis depends on the complete resection of those tumors [5–7]. Our aim was to present a case of a distal pancreatic tumor invading most of the neighboring organs—stomach, celiac axis, left renal vein, left adrenal gland, and transvers mesocolon—which was treated by en bloc resection of all these organs. Recently, distal pancreatectomy with celiac axis resection was reported as a feasible and favorable method in selected pancreatic corpus/tail tumors [1, 4,
Stereotactic Body Radiation Therapy (SBRT) for Unresectable Pancreatic Carcinoma  [PDF]
Michael C. Stauder,Robert C. Miller
Cancers , 2010, DOI: 10.3390/cancers2031565
Abstract: Survival in patients with unresectable pancreatic carcinoma is poor. Studies by Mayo Clinic and the Gastrointestinal Tumor Study Group (GITSG) have established combined modality treatment with chemotherapy and radiation as the standard of care. Use of gemcitabine-based chemotherapy alone has also been shown to provide a benefit, but 5?year overall survival still remains less than 5%. Conventional radiotherapy is traditionally delivered over a six week period and high toxicity is seen with the concomitant use of chemotherapy. In contrast, SBRT can be delivered in 3–5 days and, when used as a component of combined modality therapy with gemcitabine, disruption to the timely delivery of chemotherapy is minimal. Early single-institution reports of SBRT for unresectable pancreatic carcinoma demonstrate excellent local control with acceptable toxicity. Use of SBRT in unresectable pancreatic carcinoma warrants further investigation in order to improve the survival of patients with historically poor outcomes.
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