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Pancreatic cancer is the fourth leading cause of cancerrelated death and has the highest case fatality rate. In 2004, approximately 31,860 new cases will be diagnosed, and 31,270 of affected patients are expected to die from their disease.1 Patients usually present with advanced disease, and two-thirds of them either have locally advanced or metastatic disease. Presentation may depend on location of the primary, with more pain in patients with tumors involving the body and tail of the pancreas, and obstructive jaundice in patients presenting with pancreatic head cancer, though symptoms including weight loss, those associated with new onset diabetes, and thrombophlebitis (Trousseau’s syndrome) can occur with either presentation. The majority of patients have ductal adenocarcinoma on pathology.
For the few selected 15% to 20% of patients who present with a resectable tumor by radiographic criteria and undergo surgery, the five-year survival rate is only 20% and it is worse in node-positive patients.2,3 Determining resectability is an important first step and in most cases can be accomplished by a computerized tomography (CT) scan optimized for pancreatic imaging. Based on CT scan findings (with help from endoscopic ultrasound if needed), patients can be categorized as those with potentially resectable cancer, borderline resectable cancer, unresectable locally advanced cancer, and metastatic pancreatic cancer. Figure 1 outlines the approach to a patient with suspected pancreatic cancer.
Resectable and Borderline Resectable Pancreatic Cancer
Staging Criteria and Role of Pancreaticoduodenectomy
American Joint Committee on Cancer (AJCC) tumor, node, metastases (TNM) staging for pancreatic cancer was revised in 2002 and is presented in Table 1.4 Based on this, stages 3 and 4 are considered unresectable. Resectability criteria include a clear fat plane around celiac and superior mesenteric arteries (SMA), a patent superior mesenteric vein (SMV) and portal vein, and no distant metastases. Patients are considered to have ‘borderline’ resectable cancer if the CT scan shows cuffing or abutment to a portion of the SMA or celiac axis, severe unilateral SMV or portal vein impingement, or gastroduodenal artery (GDA) encasement up to origin at hepatic artery. These distinctions can usually be made without a pre-operative laparoscopy or endoscopic ultrasound, although most patients, once prepared for a pancreaticoduodenectomy (Whipple procedure), do undergo intra-operative laparoscopy.An additional 20% to 40% of patients may be found to be unresectable due to a small volume of peritoneal or hepatic metastases not visualized by CT. In highvolume centers, the peri-operative mortality from pancreaticoduodenectomy is less than 2%. Even after a potentially curative resection most patients recur, and five-year survivals are rare. Important prognostic features include tumor size (<2cm), lymph node involvement, and histologic grade.2,5 Post-operative complications include anastomotic leaks, delayed gastric emptying, thrombosis, infection, and bleeding.