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Surgical Management of Pancreatic Cancer

Surgical Management of Pancreatic Cancer

It is with great pleasure that I comment on the
excellent article authored by Drs. Ahrendt and Pitt, who have provided a
well-written, succinct, up-to-date review focusing on adenocarcinoma of the
pancreas. The authors introduce the topic, discuss preoperative staging and
assessment of resectability, cover the critical issues regarding resectional
therapy and palliative surgery, and provide data on the results of such therapy,
including mortality, morbidity, and quality-of-life outcomes. Emphasizing the
importance of this topic, the authors note that pancreatic cancer is the fifth
leading cause of cancer death in the United States.

In this commentary, I will focus on several issues raised by the authors and
elaborate on several new developments relevant to the early detection of
pancreatic adenocarcinoma.

Early Detection

Unfortunately, the majority of individuals in the United States are diagnosed
with pancreatic adenocarcinoma only after the tumor has disseminated from the
pancreas, involves the peripancreatic lymph nodes, and is associated with
metastases within the liver as well as systemic disease (often unimageable), for
example, in other organs and bone marrow. One of the most pressing needs in the
treatment of this disease involves early detection via screening of both the
general population and high-risk groups.

Currently, there is no accurate screening blood test for pancreatic
adenocarcinoma. Arguably, the carbohydrate antigen 19-9 (CA 19-9) is the best
available test; however, it lacks the specificity and sensitivity to be used in
the general population.[1] Recent developments in molecular genetics, serial
analysis of gene expression (SAGE), and analysis of protein expression in tumors
have led to the identification of other markers such as tissue inhibitor of
metalloproteinase type 1 (TIMP-1), prostate stem cell antigen, and mesothelin.
None of these markers are perfect, but all appear to be more accurate than
CA 19-9 in the early detection of pancreatic cancer.[2,3] As experience is
gained with these and the next generation of markers, screening of the general
population may become cost-effective. In the meantime, there is certainly
justification for screening at-risk populations.

Screening High-Risk Groups

Currently, the clinical syndromes known to be associated with an increased
risk of pancreatic cancer include hereditary pancreatitis, hereditary
nonpolyposis colorectal cancer, familial breast cancer associated with BRCA2,
the familial atypical multiple mole melanoma syndrome, Peutz-Jeghers syndrome,
and ataxia telangiectasia.[1] In addition, relatives of patients with pancreatic
cancer have an increased risk of developing the disease themselves.[4]

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