New Concepts in Diagnosis and Therapy of Pancreatic Adenocarcinoma (eBook)

New Conceptsin Diagnosisand Therapy of Pancreatic Adenocarcinoma 3
Foreword 5
Preface 6
Contents 8
Part 1: Epidemiology, ClinicalAspects and Pathology 10
Epidemiology, Risk Factors and Clinical Presentation 11
1 Epidemiology and Disease Presentation 11
2 Risk Factors 12
2.1 Genetic Risk Factors 12
2.1.1 Family History of Pancreatic Cancer 12
2.1.2 Familial Pancreatic Cancer 12
2.1.3 Other Genetic Syndromes Associated with PDAC 12
2.2 Non-genetic Risk Factors for Pancreatic Cancer 14
2.2.1 Smoking 14
2.2.2 Overweight and Obesity 14
2.2.3 Alcohol 14
2.2.4 Other Dietary Factors and Lifestyle 15
2.2.5 Diabetes 15
2.2.6 Chronic Pancreatitis 15
2.2.7 Occupational Exposure 15
2.2.8 Peptic Ulcer and H. pylori 15
2.3 Factors Associated with Decreased Risk and Potential Chemoprevention 16
References 16
Pathology and Genetics 19
1 Pathology 20
2 Prognostic Parameters of Resected Adenocarcinomas 21
3 Pancreatic Adenocarcinoma Arises from Precursor Lesions 21
4 Benign Solid and Cystic Lesions May Mimic Malignancy 22
5 Genetics 22
5.1 Hereditary Syndromes 22
5.2 Sporadic Carcinomas 23
5.3 Chromosomal Anomalies 23
5.4 Epigenetic Changes 24
5.5 Mutation in Single Genes 24
5.6 Functional Genomic Alterations 24
References 25
Part 2: Diagnosis 27
Ultrasound 28
1 Introduction 28
2 Conventional Imaging 29
3 Tissue Harmonic Imaging (THI) 29
4 Acoustic Radiation Force Impulse Imaging (ARFI) 30
5 Doppler Imaging 30
6 Contrast-Enhanced Ultrasound Imaging 31
7 Ultrasound-Guided Interventional Procedures 32
8 Typical Features of Pancreatic Ductal Adenocarcinoma 33
References 33
The Case for MDCT 35
1 Introduction 36
2 Study Protocol 36
2.1 Patient Preparation 36
2.2 Precontrast Scan 36
2.3 Early Arterial Phase 37
2.4 Pancreatic Phase 37
2.5 Portal Venous Phase 37
2.6 Late Phase 37
3 Image Postprocessing 38
4 Pancreatic Ductal Adenocarcinoma: Signs and Pitfalls 38
4.1 MDCT Tumor Identification 38
4.2 Isoattenuating Adenocarcinoma 38
4.3 Tumors Mimicking Adenocarcinoma 40
4.4 Benign Conditions Mimicking Adenocarcinoma 42
5 Tumor Staging 42
5.1 T Parameter 42
5.2 N Parameter 43
5.3 M Parameter 45
5.4 Resectability Criteria 45
6 Perioperative Findings 46
6.1 Preoperative Planning 46
6.2 Postoperative Complications and Tumor Recurrence 47
References 49
The Case for MRI 52
1 Introduction 53
2 MR Technique 53
2.1 T2-Weighted Sequences 53
2.1.1 Fast Spin-Echo (HASTE, RARE) Sequence 53
2.1.2 Conventional T2-Weighted Fast Spin-Echo Sequence 53
2.2 T1-Weighted Sequences 53
2.2.1 GRE T1-Weighted 2D Sequence with Fat Saturation 53
2.2.2 GRE T1-Weighted 3D Sequence with Small Flip Angle, Interpolation, and Fat Saturation 53
2.3 Diffusion Weighted Imaging (DWI) 56
2.4 MR Cholangiopancreatography (MRCP) 59
2.5 Secretin MRCP (S-MRCP) 59
3 MR Features of Pancreatic Carcinoma 63
3.1 Identification 63
3.2 Differential Diagnosis 67
3.2.1 Focal Chronic Pancreatitis 67
3.2.2 Groove Pancreatitis (Paraduodenal Pancreatitis, Cystic Dystrophy of Heterotopic Pancreas) 70
3.2.3 Autoimmune Pancreatitis 72
4 Staging 75
4.1 Differential Diagnosis 81
5 Post-treatment Evaluation 82
References 85
Endoscopic Ultrasonography in Pancreatic Tumors: When and Why? 88
1 Introduction 88
2 EUS and Diagnosis of Pancreatic Cancer 89
3 EUS in the Assessment of Vascular Invasion in Pancreatic Cancer 90
4 EUS-Guided FNA in Pancreatic Cancer 91
5 Molecular Markers in the Diagnosis of Pancreatic Cancer 93
References 93
PET/CT in Pancreatic Cancer 95
1 Introduction 95
2 Technique 96
3 Characterization of Focal Pancreatic Masses 97
4 Staging of Pancreatic Ductal Adenocarcinoma 97
5 Therapy Response Evaluation 98
6 Recurrent Disease 100
7. Endocrine pancreatic cancer 100
References 102
A Cost Decision Analysis for Diagnosing and Staging 104
1 Cancer and Health Economics 105
2 Pancreatic Cancer: Costs We Have to Encounter 106
3 Decision Making for Diagnosing and Staging Pancreatic Cancer 106
3.1 Summary 110
4 Screening for Pancreatic Cancer 111
References 112
Part 3: Therapy 114
The Case for Surgery 115
1 Radical Surgery 115
1.1 Duodenopancreatectomy 115
1.2 Distal Pancreatectomy 117
1.3 Total Pancreatectomy 118
2 Palliative Surgery 119
2.1 Radiofrequency Thermo Ablation 120
3 Adjuvant and Neoadjuvant Therapy 121
4 Conclusions 122
References 122
The Locally Advanced Nonmetastatic Cancer 125
1 Introduction 126
2 Prospective Trials (Table 1) 126
2.1 Chemoradiation vs. Best Supportive Care 126
2.2 Chemoradiation vs. Radiation Therapy Alone 126
2.3 Chemoradiation vs. Chemotherapy Alone 128
2.4 Chemotherapy Alone 128
3 Modalities of Chemoradiation 129
3.1 Type of Concurrent Chemotherapy 129
3.1.1 Continuous Infusional 5-Fluorouracil 129
3.1.2 Doxorubicin 130
3.1.3 Gemcitabine 130
3.1.4 Paclitaxel 130
3.1.5 Molecular-Targeted Therapies 130
3.2 Increased EBRT Dosing 131
3.3 Other Radiation Therapy Techniques 133
3.3.1 Intraoperative Radiation Therapy 133
3.3.2 Stereotactic Body Radiation Therapy 133
3.3.3 IMRT 133
3.4 A New Strategy: Induction Chemotherapy Followed by Chemoradiation 134
4 Conclusion 135
References 135
Metastatic Pancreatic Cancer: Systemic Therapy 139
1 Metastatic Pancreatic Cancer: The Clinical Problem 139
2 Chemotherapy Studies 140
2.1 Gemcitabine Monotherapy 140
2.2 Combination Chemotherapy Regimens 141
2.2.1 Gemcitabine and Fluoropyrimidines 141
2.2.2 Gemcitabine and Capecitabine 141
2.2.3 Other Combination Chemotherapy Regimens 142
2.2.4 Combination Chemotherapy Regimens: A Meta-Analysis 143
3 Targeted Therapies 143
3.1 Targeting the Epidermal Growth Factor Receptor 143
3.2 Targeting the Vascular Endothelial Growth Factor Receptor 144
4 Future Strategies 144
References 145
The Role of Interventional Endoscopy 149
1 Introduction 150
2 Preoperative Biliary Drainage 150
3 Palliation of Biliary Obstruction 150
3.1 Patient Selection: Surgery, Endoscopy, or Radiology? 151
3.2 Types of Biliary Stents 151
3.3 Plastic or Metal Stents for the Palliation of Malignant Biliary Strictures? 153
3.4 Clinical Outcomes 154
3.5 Complication of Biliary Stenting and Management of Malfunctioning Stents 155
4 Endoscopic Treatment of Pancreatic Pain 158
4.1 Obstructive Type Pancreatic Pain: The Chance for ERCP 158
4.2 Celiac Block/Neurolysis: The Chance for EUS 158
5 Gastric-Outlet Obstruction 159
5.1 Enteral Stents 160
5.2 Outcomes of Enteral Stents 160
5.3 Bilioduodenal Stenting 160
6 Ongoing Researches and Future Developments 161
6.1 Ir192-HDR Brachytherapy 161
6.2 Frontiers of Therapeutic Endoscopic Ultrasonography 162
6.3 Drug-Eluting Stents 162
References 162
Local Ablative Techniques in the Treatment of Locally Advanced Pancreatic Cancer 168
1 Introduction 168
2 Local Ablative Therapies 169
3 Future Trends and Ongoing Research 173
References 173
Index 175