Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:18

Pancreatic Cancer 1127

■bile duct strictures

■sclerosing cholangitis

management

What to Do First

■Initial assessment is directed toward whether the lesion is resectable.

Staging and resectability are performed using high-resolution spiral

CT scans and/or EUS.

specific therapy

■If resection is considered, the surgery should be performed at expe-

rienced institutions.

■Palliation

➣biliary obstruction

surgery

endoscopic stent placement

➣duodenal obstruction

surgery (e.g., gastrojejunostomy with biliary bypass)

endoscopic stent (expandable metal stents)

➣pain

opiate analgesics

intraoperative splanchnicetomy or celiac block

percutaneous celiac block

■Chemotherapy

➣long-term survival benefit is rare.

➣only 5-FU and gemcitabine have demonstrated a survival benefit

of >5 months.

➣gemcitabine may be useful for the palliation of pain.

➣adjuvant chemoradiotherapy should be considered for patients

undergoing surgery.

➣patients should be entered in investigational trials when consid-

ering chemo- or radiotherapy.

follow-up

n/a

complications and prognosis

■Prognosis remains very poor, even in many cases that initially appear

surgically resectable.

■Average 5-year survival is <5% for all patients and 17% with localized

resectable disease.

■Survival is better in carefully selected patients for surgical resection.