Adenocarcinoma of the pancreas remains a highly lethal disease, with less than 5% survival at 5 years. Borderline resectable pancreatic cancer (BRPC) and locally advanced unresectable pancreatic cancer (LAPC) account for approximately 30% of newly diagnosed cases of PC. The objective of BRPC therapy is to downstage the tumor to allow resection; the objective of LAPC therapy is to control disease and improve survival. There is no consensus on the definitions of BRPC and LAPC, which leads to major limitations in designing clinical trials and evaluating their results. A multimodality approach is always needed to ensure proper utilization and timing of chemotherapy, radiation, and surgery in the management of this disease. Combination chemotherapy regimens (5-fluorouracil, leucovorin, irinotecan, oxaliplatin, and gemcitabine [FOLFIRINOX] and gemcitabine/nab-paclitaxel) have improved overall survival in metastatic disease. The role of combination chemotherapy regimens in BRPC and LAPC is an area of active investigation. There is no consensus on the dose, modality, and role of radiation therapy in the treatment of BRPC and LAPC. This article reviews the literature and highlights the areas of controversy regarding management of BRPC and LAPC.
Implications for practice: Pancreatic cancer is one of the worst cancers with regard to survival, even at early stages of the disease. This review evaluates all the evidence for the stages in which the cancer is not primarily resectable with surgery, known as borderline resectable or locally advanced unresectable. Recently, advancements in radiation techniques and use of better combination chemotherapies have improved survival and tolerance. There is no consensus on description of stages or treatment sequences (chemotherapy, chemoradiation, radiation), nor on the best chemotherapy regimen. The evidence behind the treatment paradigm for these stages of pancreatic cancer is summarized.
摘要
胰腺的腺癌仍然是高度致死性疾病, 5 年生存率不到 5%。临界可切除胰腺癌 (BRPC) 和不可切除的局部进展期胰腺癌 (LAPC) 约占新诊断胰腺癌病例的 30%。BRPC 治疗目的是使肿瘤降期后可以手术切除, 而 LAPC 治疗目的是控制疾病和改善生存。学术界对于 BRPC 和 LAPC 的定义并未达成共识, 这导致在设计临床试验和评价试验结果时具有重大局限性。在该疾病的管理中, 确保化疗、放疗及手术正确与适时实施往往需要多学科管理手段。化疗联合方案[5-氟尿嘧啶、亚叶酸钙、伊立替康、奥沙利铂和吉西他滨 (FOLFIRINOX) 和吉西他滨/纳米紫杉醇]改善了转移性疾病的总生存。化疗联合方案在 BRPC 和 LAPC 中的作用是当前研究积极开展的领域。放疗用于 BRPC 和 LAPC 的剂量、方式和发挥的作用也尚无统一意见。本文综述了 BRPC 和 LAPC 管理方面的文献, 并强调了其中有争议的领域。The Oncologist 2016;21:178–187
对临床实践的提示: 胰腺癌是生存率最低的癌症之一, 即使在该病的早期阶段也是如此。我们对所有初步手术无法切除的肿瘤阶段 (即临界可切除胰腺癌或不可切除的局部进展期胰腺癌) 的证据进行了回顾。近期放疗技术的进展和使用更好的化疗联合方案已经改善了生存和耐受性。但在分期描述及治疗顺序 (化疗、放化疗、放疗) 以及最佳化疗方案方面仍未达成共识。我们对这些分期的胰腺癌治疗方案所依据的证据进行了总结。
Keywords: Borderline resectable; Locally advanced unresectable; Pancreatic adenocarcinoma; Pancreatic cancer.
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