Pancreatic cancer is a dismal disease with a poor prognosis and is one of the most painful malignancies. Therefore, adequate pain control is essential to improving the patient's quality of life. Pain in pancreatic cancer has complex pathophysiologic mechanisms and different characteristics. The choice of pain management modalities should be individualized depending on the pain characteristics using a multidisciplinary approach. The treatment options available include medical treatment, chemotherapy, celiac plexus/ganglion neurolysis, radiotherapy, and endoscopic technique. This review discusses the medical and interventional options, leading to optimal pain management in patients with pancreatic cancer.
Drug Therapy ; Humans ; Pain Management ; Pancreatic Neoplasms ; Prognosis ; Quality of Life ; Radiotherapy

Serine protease inhibitor Kazal-type 1 (SPINK1) is a gene expressed from pancreatic acinar cell which its mutation is known to be associated with chronic pancreatitis (CP) and pancreatic cancer. We report a case of a 47-years-old female with nausea and weight loss with yellow discoloration of skin. Initial imaging and endoscopic study led us to an impression of chronic pancreatitis with pancreatic cancer with common bile-duct dilation. Biopsy result was confirmed with pancreatic adenocarcinoma and additional imaging revealed lymph node and bone metastasis. Our genetic analysis revealed 194+2T>C mutation of SPINK1. Biliary obstruction was successfully decompressed by stent insertion and underwent chemotherapy and radiotherapy. Although there is accumulating evidence of association between SPINK1 mutation and CP, the relationship between SPINK1 mutation and pancreatic cancer in CP patient is an emerging concept. Genetic analysis should be considered in patients with young age especially when diagnosed with both CP and pancreatic cancer.
Acinar Cells ; Adenocarcinoma ; Biopsy ; Drug Therapy ; Female ; Genes, vif ; Humans ; Jaundice, Obstructive ; Lymph Nodes ; Nausea ; Neoplasm Metastasis ; Pancreatic Neoplasms ; Pancreatitis, Chronic ; Radiotherapy ; Serine Proteases ; Skin ; Stents ; Weight Loss

Pancreatic cancer is a dismal disease with a poor prognosis and is one of the most painful malignancies. Therefore, adequate pain control is essential to improving the patient's quality of life. Pain in pancreatic cancer has complex pathophysiologic mechanisms and different characteristics. The choice of pain management modalities should be individualized depending on the pain characteristics using a multidisciplinary approach. The treatment options available include medical treatment, chemotherapy, celiac plexus/ganglion neurolysis, radiotherapy, and endoscopic technique. This review discusses the medical and interventional options, leading to optimal pain management in patients with pancreatic cancer.
Drug Therapy ; Humans ; Pain Management ; Pancreatic Neoplasms ; Prognosis ; Quality of Life ; Radiotherapy

PURPOSE: Pancreatic cancer (PC) has not changed overall survival in recent years despite therapeutic efforts. Surgery with curative intent has shown the best long-term oncological results. However, 80%–85% of patients with these tumors are unresectable at the time of diagnosis. In those patients, first therapeutic attempts are minimally invasive or surgical procedures to alleviate symptoms. The addition of radiotherapy (RT) to standard chemotherapy, ergo chemoradiation, in patients with locally advanced pancreatic cancer (LAPC) is still controversial. The study aims to compare outcomes in patients with a double bypass surgery due to LAPC treated or not with RT. MATERIALS AND METHODS: A retrospective cohort study of patients with double bypass for LAPC were registered and divided into two groups: treated or not with postoperative RT. Baseline characteristics, postoperative complications, those related to RT and their relation to the main event (mortality) were compared. RESULTS: Seventy-four patients were included. Surgical complications between the groups did not offer significant differences. Complications related to RT were mostly mild, and 86% of patients completed the treatment. Overall survival at 1 and 2 years for patients in the exposed group was 64% and 35% vs. 50% and 28% in the non-exposed group, respectively (p = 0.11; power 72%; hazard ratio = 0.53; 95% confidence interval, 0.24–1.18). CONCLUSION: We observed a tendency for survival improvement in patients with postoperative RT. However, we’ve not had enough power to demonstrate this difference, possibly due to the small sample size. It is indispensable to develop randomized and prospective trials to guide more specific treatment lines in this patients.
Adenocarcinoma ; Cohort Studies ; Diagnosis ; Drug Therapy ; Humans ; Pancreatic Neoplasms ; Postoperative Complications ; Prospective Studies ; Radiotherapy ; Retrospective Studies ; Sample Size

PURPOSE: To evaluate the effectiveness and feasibility of chemoradiotherapy (CRT) using simultaneous integrated boost-intensity modulated radiotherapy (SIB-IMRT) in locally advanced pancreatic cancer (LAPC) patients. MATERIALS AND METHODS: Between January 2011 and May 2015, 47 LAPC patients received CRT using SIB-IMRT. Prior to SIB-IMRT, 37 patients (78.7%) received induction chemotherapy (IC-CRT group) and remaining 10 patients (21.3%) did not received induction chemotherapy (CRT group). During SIB-IMRT, all patients received concomitant chemotherapy, with gemcitabine (n = 37) and capecitabine (n = 10). RESULTS: At the time of analysis, 45 patients had died and 2 patients remained alive and the median follow-up time was 14.2 months (range, 3.3 to 51.4 months). For all patients, the median times of local progression-free survival (LPFS), progression-free survival (PFS), and overall survival (OS) were 18.1, 10.3, and 14.2 months, respectively. The median time of LPFS between IC-CRT and CRT groups was similar (18.1 months vs. 18.3 months, p = 0.711). IC-CRT group had a higher trend in PFS (10.9 months vs. 4.1 months, p = 0.054) and had significantly higher OS (15.4 months vs. 9.5 months, p = 0.007) than CRT group. In multivariate analysis, the use of induction chemotherapy and tumor response were significant factors associated with OS (p < 0.05, each). During SIBIMRT, toxicity of grade ≥3 was observed in 7 patients (14.9%) in all patients. CONCLUSIONS: CRT using SIB-IMRT is feasible and promising in LAPC patients.
Capecitabine ; Chemoradiotherapy ; Disease-Free Survival ; Drug Therapy ; Follow-Up Studies ; Humans ; Induction Chemotherapy ; Multivariate Analysis ; Pancreatic Neoplasms ; Radiotherapy ; Radiotherapy, Intensity-Modulated

PURPOSE: To evaluate the utility of implanted surgical clips for detecting interfractional errors in the treatment of hepatobiliary and pancreatic cancer with postoperative radiotherapy (PORT). METHODS AND MATERIALS: Twenty patients had been treated with PORT for locally advanced hepatobiliary or pancreatic cancer, from November 2014 to April 2016. Patients underwent computed tomography simulation and were treated in expiratory breathing phase. During treatment, orthogonal kilovoltage (kV) imaging was taken twice a week, and isocenter shifts were made to match bony anatomy. The difference in position of clips between kV images and digitally reconstructed radiographs was determined. Clips were consist of 3 proximal clips (clip_p, ≤2 cm) and 3 distal clips (clip_d, >2 cm), which were classified according to distance from treatment center. The interfractional displacements of clips were measured in the superior-inferior (SI), anterior-posterior (AP), and right-left (RL) directions. RESULTS: The translocation of clip was well correlated with diaphragm movement in 90.4% (190/210) of all images. The clip position errors greater than 5 mm were observed in 26.0% in SI, 1.8% in AP, and 5.4% in RL directions, respectively. Moreover, the clip position errors greater than 10 mm were observed in 1.9% in SI, 0.2% in AP, and 0.2% in RL directions, despite respiratory control. CONCLUSION: Quantitative analysis of surgical clip displacement reflect respiratory motion, setup errors and postoperative change of intraabdominal organ position. Furthermore, position of clips is distinguished easily in verification images. The identification of the surgical clip position may lead to a significant improvement in the accuracy of upper abdominal radiation therapy.
Diaphragm ; Humans ; Pancreatic Neoplasms* ; Radiotherapy* ; Respiration ; Surgical Instruments* ; Uncertainty*

PURPOSE: Neoadjuvant treatment may provide improved survival outcomes for patients with borderline resectable pancreatic cancer (BRPC). The purpose of this study is to evaluate the clinical outcomes of neoadjuvant treatment and to identify prognostic factors. METHODS: Forty patients who met the National Comprehensive Cancer Network definition of BRPC and received neoadjuvant treatment followed by surgery between 2007 and 2015 were evaluated. Prospectively collected clinicopathological outcomes were analyzed retrospectively. RESULTS: The mean age was 61.7 years and the male-to-female ratio was 1.8:1. Twenty-six, 3, and 11 patients received gemcitabine-based chemotherapy, 5-fluorouracil, and FOLFIRINOX, respectively. The 2-year survival rate (2YSR) was 36.6% and the median overall survival (OS) was 20 months. Of the 40 patients, 34 patients underwent resection and the 2YSR was 41.2% while the 2YSR of patients who did not undergo resection was 16.7% (P = 0.011). The 2YSR was significantly higher in patients who had partial response compared to stable disease (60.6% vs. 24.3%, P = 0.038), in patients who did than did not show a CA 19-9 response after neoadjuvant treatment (40.5% vs. 0%, P = 0.039) and in patients who did than did not receive radiotherapy (50.8% vs. 25.3%, P = 0.036). Five patients had local recurrence and 17 patients had systemic recurrence with a median disease specific survival of 15 months. CONCLUSION: Neoadjuvant treatment followed by resection is effective for BRPC. Pancreatectomy and neoadjuvant treatment response may affect survival. Effective systemic therapy is needed to improve long-term survival since systemic metastasis accounts for a high proportion of recurrence.
Drug Therapy ; Fluorouracil ; Humans ; Neoadjuvant Therapy* ; Neoplasm Metastasis ; Pancreatectomy ; Pancreatic Neoplasms* ; Prognosis ; Prospective Studies ; Radiotherapy ; Recurrence ; Retrospective Studies ; Survival Rate

PURPOSE: This study assessed the feasibility and compliance of induction chemotherapy with gemcitabine and cisplatin followed by simultaneous integrated boost–intensity modulated radiotherapy (SIB-IMRT) with concurrent gemcitabine in patients with locally advanced unresectable pancreatic cancer. MATERIALS AND METHODS: In this trial, patients received induction chemotherapy consisting of gemcitabine (1,000 mg/m²) and cisplatin (25 mg/m²) on days 1, 8, and 15 of each treatment cycle. Patients were subsequently treated with gemcitabine (300 mg/m²/wk) during SIB-IMRT. The patients received total doses of 55 and 44 Gy in 22 fractions to planning target volume 1 and 2, respectively. As an ancillary study, digital polymerase chain reaction was performed to screen for the seven most common mutations in codons 12 and 13 of the KRAS oncogene of circulating cell free DNA (cfDNA). RESULTS: Forty-four patients were enrolled between 2012 and 2015. Of these, 33 (75%) completed the treatment. The most common toxicities during induction chemotherapy were grades 3 and 4 neutropenia (18.2%), grade 3 nausea (6.8%) and vomiting (6.8%). The most common toxicities during SIB-IMRT were grade 3 neutropenia (24.2%) and grade 3 anemia (12.1%). Ten patients (23%) underwent a curative resection after therapy. Median overall survival was significantly longer in patients who underwent curative resection (16.8 months vs. 11 months, p < 0.01). The median cfDNA concentration was significantly lower after treatment (108.5 ng/mL vs. 18.4 ng/mL, p < 0.001). CONCLUSION: Induction chemotherapy with gemcitabine and cisplatin followed by concurrent SIB-IMRT was well tolerated and active.
Anemia ; Cisplatin* ; Codon ; Compliance ; DNA ; Feasibility Studies* ; Humans ; Induction Chemotherapy* ; Nausea ; Neutropenia ; Oncogenes ; Pancreatic Neoplasms* ; Polymerase Chain Reaction ; Radiotherapy* ; Vomiting

A rare case of delayed large epidural mucin collection causing neurologic deficit after surgery for metastatic pancreatic cancer is reported. A 65-year-old man presented with intractable upper-thoracic back pain radiating to the chest and gait disturbance. He had a history of subtotal pancreatectomy due to intraductal papillary mucinous neoplasm (IPMN) of the pancreas and concurrent chemotherapy. Eight months after pancreatectomy, multiple thoracic spinal metastasis was diagnosed with routine up positron emission tomography-computed tomography. Radiotherapy for spinal metastasis and subsequent chemotherapy was carried out. Sixteen months after pancreatectomy, gait disturbance occurred and follow-up thoracic magnetic resonance imaging (MRI) showed aggravation of metastasis at T2 and T4 compressing the spinal cord. We performed a decompressive laminectomy with subtotal resection of the tumor masses and pedicle screw fixation at C7–T6. Neurologic status improved after the operation. Histopathologic examinations revealed the tumor as metastatic mucin producing adenocarcinoma. Three months after surgery, motor weakness and pain was reappeared. MRI showed large amount of epidural fluid collection. We performed wound revision and there was large amount of gelatinous fluid at the epidural space. We suggest that postoperative mucin collection and wound problems should be considered after surgery for mucin producing metastatic pancreatic tumor.
Adenocarcinoma* ; Aged ; Back Pain ; Drug Therapy ; Electrons ; Epidural Space ; Follow-Up Studies ; Gait ; Gelatin ; Humans ; Laminectomy ; Magnetic Resonance Imaging ; Mucins* ; Neoplasm Metastasis ; Neurologic Manifestations ; Pancreas ; Pancreatectomy ; Pancreatic Neoplasms ; Pedicle Screws ; Radiotherapy ; Spinal Cord ; Spinal Neoplasms ; Thorax ; Wounds and Injuries

Locally advanced pancreatic cancer is associated with a very poor prognosis. This study was performed to evaluate whether patients with locally advanced pancreatic cancer benefit from (125)I seed implantation. This retrospective study included 224 patients with locally advanced pancreatic cancer, with 137 patients (61.2%) in the implantation (IP) group and 87 (38.9%) in the non-implantation (NIP) group. The survival status, complications and objective curative effects were compared between the groups. The average operative time in the IP group was significantly longer than that in the NIP group (243±51 vs. 214±77 min). The tumor response rates were 9.5% and 0 at the 2nd month after surgery in the IP and NIP groups, respectively (P<0.05). The IP group exhibited a trend toward pain relief at the 6th month after surgery. The global health status scores of the IP group were higher than those of the NIP group at the 3rd and 6th month after surgery. The median survival time in the IP group was significantly longer than that in the NIP group. In conclusion, patients with locally advanced pancreatic cancer can benefit from (125)I seed implantation in terms of local tumor control, survival time, pain relief and quality of life.
Adult ; Aged ; Drug-Eluting Stents ; adverse effects ; Female ; Humans ; Iodine Radioisotopes ; administration & dosage ; therapeutic use ; Male ; Middle Aged ; Pancreatic Neoplasms ; pathology ; radiotherapy ; Quality of Life ; Radiopharmaceuticals ; administration & dosage ; therapeutic use ; Survival Analysis