Diagnosis and Treatment

Initial diagnosis of pancreatic cancer occurs with a basic external physical exam, which can detect physical masses (e.g. tumor masses or an enlarged liver if the cancer has spread) or fluid build-up in the abdomen. Yellow skin or eyes are indicative of jaundice, which may be another initial warning sign, as are enlarged lymph nodes. Detection of symptoms such as these indicate further testing.

Blood Tests

Several types of blood tests may be used to help diagnose pancreatic cancer:

• Liver Functions: in individuals with jaundice, tests that look at bilirubin levels may be used to determine whether the jaundice is liver related; if not it may indicate a blockage of bile flow, which may indicate a tumor.

• Tumor Markers: CA 19-9 and CEA are both markers that are released in advanced cases of pancreatic cancer, but neither is reliable enough to be definitive without additional tests.

• Pancreatic Hormone Levels: Blood levels of pancreatic hormones such as insulin, glucose, C-peptide, gastrin, glucagon, somatostatin, pancreatic polypeptide, and vasoactive intestinal peptide may be elevated in cases of pancreatic cancer. Again, since there are other reasons why these hormone levels may be higher than expected, these blood tests are not in and of themselves definitive of pancreatic cancer.

The frequency of blood draws from cancer patients makes it relatively easy to prospectively collect blood-derived pancreatic cancer samples such as serum and plasma, but scientists need to be realistic about volumes, custom protocols or anything else that deviates from standard care protocols. The more your collection requirements deviate from standard care, the harder the request will be to fill.

Imaging Tests

A variety of imaging tests may be used to diagnose and stage pancreatic cancer. These are generally very reliable, as they are able to see through the dense abdominal tissues surrounding the pancreas. These include general tissue-scan systems such as CT, MRI, and PET scans. More targeted approaches include cholangiopancreatographies (endoscopic, MRI, and x-ray based), which are able to specifically image the pancreas. Endoscopic cholangiopancreatography utilizes x-ray contrast dyes to highlight the bile ducts in the pancreas.

Somatostatin Receptor Scintigraphy is a specialized type of imaging used to detect several different forms of cancer, including pancreatic cancer. Radiolabelled ocreotide (a somatostatin analog) is injected intravenously and attaches to tumor cells, which tend to express Somatostatin receptors at relatively high levels (sun coy curr drug deliv). Imaging is then performed using a large-field-of-view gamma camera (society of nuclear medicine proc 2002).

Another specialized form of medical imaging commonly used to detect and stage pancreatic cancer is angiography (also known as arteriograpy). Angiography utilizes a radio-opaque dye, which is injected into the celiac and superior mesenteric arteries to ensure that the pancreatic vessels are fully permeated. X-ray fluoroscopy is then used to detect the structure of the blood vessels within the pancreas, which can indicate the severity of pancreatic lesions.

Biopsy

While blood and imaging tests can suggest the presence of pancreatic cancer, only a tissue biopsy followed by microscopy can conclusively diagnose this disease. Fine-needle aspiration (FNA) or endoscopic ultrasound-guided biopsies are performed under imaging guidance, allowing a clinician to capture samples directly from the tissue mass. Endoscopic cholangiopancreatography (one of the imaging methods described above) can also be combined with a physical collection of tissue, as can an endoscopic ultrasound.

From: De La Cruz et al., 2014; Hanada et al., 2014; Yamaguchi et al., 2014

Treatment

Treatment of pancreatic cancer varies depending on the severity and stage of the disease. Standard treatments include surgical or ablative removal of cancerous tissues, radiotherapy, and chemotherapy.

Typically if the cancer has not spread beyond the pancreas, it is considered resectable and surgical removal is the preferred treatment. Depending on the location of the tumor, a pancreaticoduodenectomy or distal pancreatectomy is performed. In some cases it may be discovered during surgery that complete removal is not possible. In either case, since pancreatic cancer has a high frequency of recurrence, additional post-surgical chemo or radiotherapy is prescribed. Because of this, it is common to begin chemo or radio therapies before surgery if the patient is healthy enough.

If the cancer has spread, surgery is typically bypassed and chemo and radiotherapies are used exclusively.

The most common drug used in cases of pancreatic cancer is gemcitabine (Gemzar). Frequently this is part of a multi-drug therapy including paclitaxel (Abraxane), erlotinib (Tarceva), or capecitabine (Xeloda). Alternately a cocktail of drugs, FOLFIRINOX, may be used. FOLFIRINOX combines 5-FU, leucovorin, irinotecan (Camptosar), and oxaliplatin (Eloxatin). While FOLFIRINOX has been shown to extend the lifespan of patients with pancreatic cancer, it has more severe side effects, and as such may be limited to individuals who are otherwise healthy (Tourkantonis, Peponi, Syrigos, & Saif, 2014).

Looking Forward

There has been some promising research using genetically engineered viruses in the treatment of pancreatic cancer. Oncolytic virotherapy takes advantage of the strong target specificity of certain viruses to deliver these engineered viruses directly to the tumor cells. Most recently a study using a modified form of the Vaccinia virus containing IL-10 demonstrated a long-term protection against recurrence of pancreatic cancer (a common problem) in a mouse model (Chard et al., 2014), and resulted in an increased frequency of tumor-specific T cells. While no human trials have been scheduled, virotherapies in general, and this modified Vaccinia virus, show great promise in the future treatment of this fatal disease.

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