Info

🌱來自：pancreatic cancer

Treatment of pancreatic adenocarcinoma

(Lancet 2016;388:73)

• Resectable: pancreaticoduodenectomy (Whipple procedure) + adjuvant chemo: modified FOLFIRINOX (5-FU + leucovorin, irinotecan, oxaliplatin) if ECOG 0-1 (NEJM 2018;379:2395), o/w gemcitabine + capecitabine (Lancet 2017;389:1011). Gemcitabine monoRx recently standard, but now w/ ↓ role. Role of RT is controversial.
• Borderline: goal to ↓ tumor to allow complete resection (R0 – neg margin at histology) using neoadjuvant Rx (various approaches tested). General schema: chemo ± RT → restage & potential resection depending on response. May need vasc. reconstruction during resection. Regimens include: FOLFIRINOX; gemcitabine + nab-paclitaxel.
• Locally advanced (ie, unresectable): Rx is typically palliative. However, in highly select Pts recent trend toward Rx w/ FOLFIRINOX plus XRT followed by laparotomy for response assessment (imaging can be unreliable) and potential resection.
• Metastatic: clinical trials preferred; Rx based on performance status (PS) Good PS: FOLFIRINOX, gemcitabine + nab-paclitaxel (NEJM 2013;369:1691); germline BRCA1/2 mut: maintenance olaparib (NEJM 2019;381:317) also ↑ response to platinum combination chemo (eg, cisplatin w/ gemcitabine), ICI for MSI-high. Poor PS: gemcitabine; capecitabine; continuous infusion 5-FU
• Palliative care: Biliary/gastric outlet obstruct.: endoscopic stenting, IR drain, surg bypass. Pain: opiates, celiac plexus neurolysis, XRT. Wt loss: enzyme replacement.

Regimen	Citation	ORR (%)	Median PFS (mos)	Median OS (mos)
FOLFIRINOX	NEJM 2011:364:1817	32	6.4	11.1
GEM + nab-P	NEJM 2013:369:1691	23	5.5	8.5
GEMOX	Br J Cancer 2006:94:3778	23	4	6
GEM + Cape	JCO 2009: 27:5513	19	5	7
GEM	Multiple trials	10-15	2.3	5-7
CapeOx	Cancer 2008:113:2046	3	2.5	5.8

• FOLFIRINOX = 5-FU/LV, irinotecan, and Oxaliplatin
• nab-P = nab-paclitaxel
• Except for CapeOx, all regimens were compared to GEM (Gemcitabine) in randomized phase II or III studies.