Pancreatic Cancer

Question 1

Generally, 2 Chemo-regimen for Stage IV or locally advanced/invasive Pancreatic Cancer?

Answer 1

1. FOLFIRINOX (5-FU, Leucovorin [Folinic acid], Irinotecan, Oxaliplatin)
2. Gemcitabine + NAB-Paclitaxel (nano-particle-albumin bound)

Question 2

Benefits of early palliative care involvement?

Answer 2

1. Improve QOL
2. Improve survival
3. Patient & family satisfaction
4. Reduces prolonged grief and PTSD for family
5. Reduced rate of unnecessary hospital admissions

Question 3

What kind of pain do pancreatic Ca patients get?

Answer 3

mid-epigastric pain that radiates bilaterally under the ribs to the mid-back

Pain maybe neuropathic in nature, given the proximity of tumor to celiac plexus (hence requirement for Gabapeintin, pregabalin, SSRIs).

Question 4

What are the options for the management of pain in Pancreatic Cancer? (5)

Answer 4

1. Opioids
2. Gabapentinoids - neuropathic pain from coeliac plexus
3. SSRI/TCAs - ditto.
4. CPN (Coeliac Plexus Nerulysis) - more effective than Pharm alone with a success rate up to 67% - better pain control, less opioid consumption
5. RTx - a short, palliative RTx can sig alleviate pain due to local invasion of cancer - with/without chemo can result in resolution of cancer-related pain in 35-65% of patients, with improvement in cachexia/obs symptoms. May take several weeks. Effect is faster with CPN hence is the preferred approach.

Question 5

What are the options for jaundice in pacnreatic cancer?

Answer 5

1. Palliative stent
2. Surgical bypass - but sig post/peri-op mortality (3-22%), median surv 6.5 months. Reserved for those who cannot have stent for technical reasons. Cholecysto- or Choledocho-jejunostomy (i.e. GB or CBD to jejunum)

Question 6

Difference between Plastic vs. metal stents for Pancreatic cancer?

Answer 6

Metal stent lasts longer (8-12 months) than plastic (~3 months), but more expensive and may not be removable.

Plastic stents are cheap and can easily be removed/exchanged. However, they eventually develop occlusion by sludge and/or bacterial biofilm. Lasts only 3 months.

Question 7

Why does pancreatic cancer patients get delayed gastric emptying resulting in anorexia, nausea, and vomiting?

Answer 7

It’s not just due to Gastric or Duodenal obstruction from the tumour.

This can be even seen without evidence of gastroduodenal tumour invasion. Probably due to tumour infiltration into the nerve plexus, resulting in delayed emptying.

In such situations, gastrojejunostomy do not work in relieving symptoms.

Question 8

So what are the options for delayed gastric emptying in pancreatic cancer?

Answer 8

Metoclopromide

Decompression using venting PEG

Question 9

Why is it important to control depression and anxiety in pancreatic cancer patients?

Answer 9

Worsens QOL

Experiences more intense pain

Question 10

Mechanisms of cancer-associated cachexia? (4)

Answer 10

1. Hypercatabolic state + accelerated loss of skeletal muscles in cont of chronic inflammation
2. Loss of appetite + weight loss
3. Cytokine activation + tumour derived cachexia inducing substances (e.g. TNF-a, IL1, 6)
4. Decreased absorption from Panc exocrine insufficiency