Evolving strategies for the treatment of adenocarcinoma of the pancreas. A review.

Adenocarcinoma of the pancreas has an incidence of only 0.01%, yet is the fourth leading cause of cancer death for American men and women. Despite this dismal outlook, new strategies for staging and therapy for pancreatic cancer have emerged over the last few years. Laparoscopy with cytologic evaluation of peritoneal washings, and more recently, although still investigational, endoscopic and intracorporeal ultrasonography have provided more detailed staging information. The result of improved staging is earlier, more accurate selection of treatment most appropriate for stage of disease. For those patients with clinically localized disease, laparotomy with an attempt at resection is indicated, particularly with the recent trend in declining morbidity and operative mortality the recent trend in declining morbidity and operative mortality associated with pancreatectomy. With clinically unresectable disease, patients may potentially be spared the morbidity of laparotomy. Advances in therapeutic endoscopic and percutaneous manipulation of the obstructed biliary tree have provided an alternative to surgery and improved quality of life for patients with abbreviated life spans. Gastroduodenal obstruction has traditionally been managed by laparotomy, although with improved technology and surgical skill, a laparoscopic approach may become standard. Because even at presentation pancreatic cancer is rarely a localized process but is a disseminated disease, surgery alone is unlikely to increase survival rates in the absence of adjuvant therapies. Present and future strategies for treatment include the addition of neoadjuvant regimens and adjuvant modalities including intraoperative radiation, photodynamic therapy, intraperitoneal therapies, and pancreatic and splanchnic perfusion. Clearly, the greatest strides in treatment of pancreatic cancer will come with development of new agents with significantly greater antitumor efficacy.