It is hard to stage pancreatic cancer accurately by imaging tests. Doctors must do their best to decide before surgery whether there is a good chance the cancer can be completely removed. Surgeons usually consider an exocrine pancreatic cancer resectable (completely removable by surgery) if it is staged as T1, T2, or T3. That means it doesn't extend far beyond the pancreas, especially into nearby large blood vessels (T4). There is no accurate way to assess the lymph node spread of the tumor before surgery.

Exocrine pancreatic cancer

Resectable: If imaging tests show a reasonable chance of completely removing the cancer, surgery should be done if possible, as it offers the only chance to cure this disease. Based on where the cancer started, either a pancreaticoduodenectomy (Whipple procedure) or a distal pancreatectomy is usually used.

In most but not all cases, either chemotherapy alone or chemotherapy plus radiation therapy (chemoradiation) is used as well. This treatment may be given before or after surgery. Some centers favor giving it before surgery because the recovery after surgery is often long, which can delay or even prevent its use. But it is not yet clear whether this approach is better than giving it after surgery. Many surgeons are concerned about preoperative therapy. They feel that patients may become weakened and are therefore less able to withstand the surgery.

A recent study has shown that giving gemcitabine chemotherapy after surgery can delay the average time before cancer returns by about 6 months. It also seems to help patients live longer. 5-FU was commonly used in the past after surgery, but now gemcitabine is used more often. There is currently an ongoing study comparing 5FU and gemcitabine as adjuvant therapy to see if one is better than the other. It is not yet clear whether adding radiation to chemotherapy would result in more of a benefit.

Locally advanced: Locally advanced cancers of the pancreas are those that have grown too far to be completely removed by surgery, but have not yet reached distant parts of the body. Several studies have shown that attempts to partially remove these cancers do not help patients to live longer. Therefore, surgery has a limited role in these cancers. It is used mainly to relieve bile duct blockage or to bypass a blocked intestine caused by the cancer pressing on other organs.

The standard treatment options for locally advanced cancers are chemotherapy with gemcitabine either alone or along with radiation therapy. One study showed that combining radiation with gemcitabine helped patients with locally advanced cancers live longer than giving gemcitibine by itself. Another study gave patients with locally advanced disease chemotherapy and radiation together and then rechecked the patients to see if the cancer has shrunk enough to be completely removed by surgery. Some patients were then able to have surgery.

Metastatic (widespread): Because these cancers have spread through the lymphatic system or bloodstream, they cannot be removed by surgery. These cancers have also spread too far to be treated by radiation therapy alone. Even when imaging tests show that the spread is only to one area of the body, it has to be assumed that small groups of cancer cells (too small to be seen on imaging tests) are already present in other organs of the body.

Chemotherapy with gemcitabine is the standard treatment for advanced pancreatic cancer. It can cause the cancer to shrink and help patients live longer. People who get chemotherapy also seem to have fewer symptoms related to their cancer. Adding other drugs to gemcitabine may improve the chance the tumors will shrink and may help people live longer. So far, only erlotinib and capecitabine have been shown to help some patients live longer when given along with gemcitabine. Overall, the benefit of giving erlotinib along with gemcitibine was very small (patients lived about 2 weeks longer). Erlotinib doesn't seem to help all patients, so experts are trying to find a way to figure out who should get the drug and who try something else. Capecitabine also only seemed to help some of the people who received it with gemcitabine. Most doctors give chemo with gemcitabine for pancreatic cancer, and consider adding another drug on a case-by-case basis.

Because the treatments now available don't work well for most patients, people may want to think about taking part in a clinical trial involving chemotherapy combinations (with or without radiation therapy) and new targeted therapies.

Doctors don't agree on what is the best therapy to give someone when gemcitabine stops working. If a patient wants more treatment and is strong enough, different chemo drugs may be used. Some patients are given one of the targeted agents. Enrolling in a clinical trial may be the best choice at this point.

Recurrent cancer: Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the liver, lungs, or bone). When pancreatic exocrine cancer recurs, it is essentially treated the same way as metastatic cancer, and is likely to include chemotherapy if the patient can tolerate it.

Cancer of the ampulla of Vater

The ampulla of Vater is the area where the pancreatic duct and the common bile duct empty their secretions into the duodenum (the first part of the small intestine). Cancer of this site can arise from the pancreatic duct, the duodenum, or the common bile duct. Surgery with pancreaticoduodenectomy (Whipple procedure) is often successful as cancer treatment with a 5-year survival rate of 30% to 50%. More advanced ampullary cancers are treated like pancreatic cancer. In many patients, ampullary cancer cannot be distinguished from pancreatic cancer until surgery has been done. Post-operative chemoradiotherapy is often recommended in patients who have had successful resection of their ampullary carcinoma.

Pancreatic endocrine tumors

If the tumor is resectable, it will be removed by surgery. What procedure is used depends on the type of tumor, its size, and its location in the pancreas. Surgery can range from as little as enucleation to as much as a pancreatoduodenectomy (Whipple procedure). Lymph nodes are often removed to check for tumor spread. Laparascopy may be done before resection to better locate and stage the tumor. Prior to any surgery, medications are often given to control the symptoms caused by the tumor. For gastrinomas, drugs to block stomach acid are used (like proton pump inhibitors). Often, people with insulinomas are treated with diazoxide to keep the blood sugar from getting too low. If the tumor was visible on somatostatin receptor scintiography, octreotide may be used to control any symptoms. After surgery, the patient will be watched closely for signs that the cancer may have come back or spread.

If the cancer has spread, medications may be used to control symptoms. Surgery or ablative techniques may be used to treat metastases in the liver. If the cancer has spread widely, treatment with chemo is an option.

Last Medical Review: 10/13/2009
Last Revised: 10/13/2009