[Adenocarcinoma of the pancreas. Therapeutic strategies].

SURGERY

Surgery whether curative or palliative, is the major modality of treatment. A complete resection is possible in about 20% of patients with a median survival of 12 to 16 months and a 20% five year survival. After complete resection 70 to 80% of patients develop a local recurrence. Biliary and gastro-intestinal bypasses as well as antalgic techniques are useful palliative procedures.

ADJUVANT AND NEOADJUVANT TREATMENT

Chemoradiotherapy is used either as adjuvant or neoadjuvant treatment. External beam irradiation techniques are used to deliver 45 to 50 Gy to the pancreas in five to six weeks. Concomitant fluorouracil is administered in bolus injections or better in continuous infusion,, either alone or in association with cisplatinum. Chemoradiotherapy reduces the local relapse rate and slightly, though significantly, increases the median survival. Therefore, after chemoradiotherapy, metastatic spread becomes the major cause of death.

PALLIATIVE TREATMENT

For locally advanced diseases, chemoradiotherapy has a true palliative effect with acceptable toxicity. Metastatic disease remains a challenge. Fluorouracil based chemotherapy with or without cisplatinum occasionally obtains effective palliation. Among new agents, only gemcitabine has proven clinical activity associated with low toxicity and is practical to use.

THERAPEUTIC STRATEGY

Presently, patients with resectable pancreatic carcinoma should be included in a prospective trial to receive combined modality treatment with adjuvant or neo-adjuvant chemoradiotherapy. The choice of treatment for patients with locally advanced or metastatic disease, should be based on the possibility of assuring a satisfactory quality of life. Present research should progress through controlled clinical trials to study original systemic treatment and combined modalities able to produce a lasting local control.