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Daily Gendai Healthcare
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Pancreatic cancer(Pancreatic cancer,British: Pancreatic cancer, Abbreviation:PaC) IspancreasOriginated fromcarcinoma.Pancreatic cancerAlso called (pancreatic cancer).Early detection is very difficult, progress is fast, and it is extremely difficult.prognosisIs bad.
As a subjective symptomstomach acheAlthough there are symptoms such as weight loss and weight loss, there are no specific symptoms, most of them are asymptomatic in the early stage, and many are often found after they have progressed.Complete medical checkupOr by chanceCT,UltrasonographyIn pancreatic hook and pancreatic head cancer, the tumor occludes the common bile duct, except as detected by imaging tests.jaundiceOr causeoxygenDue to deficiencyLangerhans IslandDue to hypoactivityDiabetes mellitusIs getting worse or I have no ideaBlood glucose level,amylaseIt may take the form of an increase in value.
Ministry of Health, Labor and WelfareAccording to the statistics, the number of pancreatic cancer deaths in Japan is more than 22,000 every year, and the number of cancer deaths is 5th for men and 6th for women, and is increasing year by year.
|Deaths (2017)||Number of cases (2014)|
|Male||Female||men and women||Male||Female||men and women|
Risk factors for onset include:.
- smoking --Two to three times more risk than non-smokers
- obesity・ Lack of exercise-double the risk
- Over the long termDiabetes mellitus - 2 times
New pancreatic cancer was noted in 1.14% of diabetic patients hospitalized for worsening glycemic control.
Genetic Syndrome and Related Genes
- Hereditary pancreatitis (PRSS1, SPINK1)-Approximately 50% develop.
- Familial atypical multiple mole and melanoma syndrome, abbreviation:FAMMM) (P16) -10% to 20%
- Hereditary Breast Cancer Ovarian Cancer Syndrome (BRCA1, BRCA2, PALB2) ―― 1% to 2%
- Peutz-Jegers Syndrome (Peutz-Jegher's Syndrome) -30% to 40%
- Hereditary non-polyposis colorectal cancer (Hereditary non-polyposis colon cancer, abbreviation:HNPCC, Lynch syndrome) (MLH1, MSH2, MSH6) -4%
- Capillary diastolic ataxia (Ataxia Telangiectasia) --The merger rate is unknown.
- Li-Fraumeni Syndrome-Unknown complication rate.
Hereditary diseases such as hereditary pancreatitis, familial adenomatous polyposis, FAMMM, and Peutz-Jeghers syndrome have a high incidence of pancreatic cancer and are also called hereditary pancreatic cancer syndrome.
Relationship with diabetes
In Japanese,Diabetes mellitusIs associated with an increased risk of pancreatic cancer.It may be associated with common risk factors for diabetes and cancer (aging, obesity, poor diet, lack of exercise).The mechanism by which diabetes increases the risk of pancreatic cancer isHyperinsulinemia,High blood sugar,InflammationAnd so on.
It is classified as follows according to the site of occurrence.
- Pancreatic hook cancer
- Pancreatic Head Cancer-60% of pancreatic cancers occur in the head of the pancreas.
- Pancreatic body cancer
- Tail of pancreas cancer
PancreasPancreatic juiceTo produceAcinus, Carry pancreatic juicePancreatic duct,andEndocrine glandsIsLangerhans IslandAnd so on.Cancer can come from any tissue, but each becomes a tumor with completely different properties.
- Invasive pancreatic ductal cancer (Invasive ductal carcinoma)-A typical histological type that accounts for about 90% of pancreatic cancer, also called normal pancreatic cancer.Derived from the pancreatic duct.
- Pancreatic endocrine tumor --Derived from the endocrine glands (Langerhans islets), about 8% is somethinghormoneTo produce.Compared to normal pancreatic cancerAnti-cancer agentIs hard to work, but the progress is slow.
- Intraductal papillary mucinous tumor (English: intraductal papillary-mucinous neoplasms, Abbreviation: IPMNs) --A tumor that develops from the epithelium of the pancreatic duct and is characterized by intraductal growth and mucus production.Generally, the malignancy is low and follow-up is possible, but those with findings of malignancy are targeted for surgical treatment.
- Mucinous cyst tumor (English: mucinous cystic tumors, Abbreviation: MCTs)-Large, multilocular cystic lesions with mucus, most common in middle-aged women.It is highly malignant and is treated according to conventional pancreatic cancer.
- Acinic cell carcinoma --A relatively rare tumor derived from the acinus.
- Other rare histological types-Solid-pseudopapillary carcinoma, undifferentiated cancer, serous cystadenocarcinoma (extremely rare), metastatic pancreatic cancer, etc.
- Tumor marker: The following values are used as indicators by indicating high values.
Evaluation is performed by performing the following image inspection.
- Generally used in medical examinations.Typical pancreatic ductal carcinoma is depicted as an unclear and irregular hypoechoic region.Dilation of the main pancreatic duct and bile duct is also observed in cancer of the head of the pancreas.
- Non-contrast examination lacks clinically useful information and contrast is essential.Since pancreatic ductal cancer has poor blood flow, it is visualized as a poorly contrasted area rather than the pancreatic parenchyma in the early stage of contrast enhancement (arterial phase), but it is evaluated because it shows the same contrast effect as the pancreatic parenchyma in the late contrast phase (equilibrium phase). Becomes difficult.On the other hand, pancreatic endocrine tumors are rich in blood flow and are strongly contrast-enhanced by contrast-enhanced CT.RemoteTransition・ You can also evaluate the infiltration image to the surroundings.
- MRCP images that depict the bile duct and pancreatic duct can evaluate irregularities, stenosis, and disruption of the pancreatic duct.Contrast-enhanced MRI can be evaluated in the same way as contrast-enhanced CT.
- Abnormal accumulation is seen consistent with cancer, but it is often difficult to distinguish it from inflammation.
- Endoscopic retrograde cholangiopancreatography (Endoscopic retrograde cholangio-pancreatography, abbreviation: ERCP)
- This is a method of directly imaging the bile duct and pancreatic duct with an endoscope.In pancreatic ductal cancer, irregular stenosis or interruption of the pancreatic duct is seen, and cytodiagnosis can be performed.
- Endoscopic ultrasound (Endoscopic ultrasonography, abbreviation: EUS)
- An ultrasonic probe is attached to the tipEndoscopeUsestomachInsideduodenumUltrasonography to observe from inside.Puncture cytology of tumors can also be performed.
There are two types of pancreatic cancer staging, the Pancreatic Cancer Handling Regulations of the Japanese Pancreatic Society and the international UICC classification. In Japan, the degree of progression of the Japanese Pancreatic Society is mainly used.BothTNM classificationBased on, it is divided into 4 stages of progress (stage).
- Pancreatic cancer handling rules(5rd edition)[Broken link]
- Stage I-Limited to the inside of the pancreas with a size of 2 cm or less.
- Stage II-The cancer remains inside the pancreas but is larger than 2 centimeters or has spread to lymph nodes in group 1.
- Stage III-Cancer extends slightly outside the pancreas but has no lymph node metastases or is limited to group 1.Alternatively, the cancer remains inside the pancreas, but lymph node metastases are up to group 2.
- Stage IV-The cancer involves or has spread to distant organs around the pancreas.
- UICC classification (6th edition)
- Stage I-The cancer remains inside the pancreas and has not spread.
- Stage II-The cancer stays inside the pancreas but has spread to the surrounding lymph nodes.Alternatively, the cancer has spread slightly out of the pancreas but has not reached the major arteries.
- Stage III-A tumor of the pancreas extends to the surrounding major arteries.
- Stage IV-Metastases to organs distant from the pancreas.
Depending on the degree of progress, surgery, whole bodychemical treatment,Radiation therapy, Or a combination of these.The degree of progression can be divided into the following three stages from the viewpoint of treatment.
- Resectable --The stage where the cancer is localized around the pancreas and there is no infiltration of important blood vessels or distant metastasis.For pancreatic cancer below Stage IVa according to the Pancreatic Cancer Handling Regulations,Celiac artery(Pancreatic head cancer)Superior mesenteric arteryThose that do not infiltrate are applicable.Surgical resection is the treatment of choice.
- Local progression -A stage in which the cancer is localized around the pancreas but is considered unresectable due to infiltration of important blood vessels and widespread extension to the retroperitoneum.Chemoradiation or systemic chemotherapy is being given.
- With distant metastasis --The stage where the cancer has spread to the whole body beyond the perimeter of the pancreas.liverMostly due to metastasis to or peritoneal dissemination.At this stage, even if all visible cancer is removed, it will recur early, and it is believed that there is no therapeutic benefit from pancreatic resection.Systemic chemotherapy is the treatment of choice.
Surgical resection is the definitive treatment, but it is often advanced at the time of discovery and is often inoperable.
- Clinical stage classification Stages 0 to III can be operated: Preoperative chemotherapy (GEM + S-1 therapy) + definitive resection with surgical treatment combined with postoperative adjuvant chemotherapy.
- Clinical staging Stages II to III Inoperable: Chemoradiation or chemotherapy
- Clinical staging Stage IV: Chemotherapy
Including tumorPancreatectomyIs done.mostInvasionBecause it is one of the major surgeries, indications are considered in consideration of the patient's age and general condition.Since it is a high-difficulty operation, it is desirable to perform the operation at a highly specialized medical institution or a high volume center (hospital with a large number of operations).
- Pancreatic head cancer / pancreatic hook cancer:Pancreaticoduodenectomy (PD)
- Pancreatic body cancer / pancreatic tail cancer: Pancreatic body tail resection
In addition, total pancreatectomy has a prognosis.QOLIt is becoming less common in consideration of.Also, around the abdominal aorta and around the superior mesenteric arteryLymph node dissectionIs not being performed because of the large surgical invasion and the lack of improvement in survival rate.
In addition,Irreversible electrosurgical methodThere is (commonly known as nanoknife), and in this case, there are two possible ways, laparotomy and puncture, and in the latter case, the degree of invasiveness is low.
It is characterized by being able to treat unresectable pancreatic cancer that has invaded blood vessels.
Performed after surgical resectionchemical treatmentThere are the following.
- GEM (Gemcitabine) Monotherapy: The standard treatment worldwide. In the CONKO-001 study, it was superior to the control group placebo.
- S-1Monotherapy: Standard treatment in Japan. The JASPAC-01 trial was superior to the control group of GEM monotherapy.
- GEM +CapecitabineCombination therapy: The ESPAC-4 trial significantly prolonged survival compared to GEM monotherapy.
- Modified FOLFIRINOX therapy: Excellent results compared to GEM monotherapy in the control group.
In a study examining the effects of preoperative chemotherapy, GEM + S-1 therapy was given preoperatively because survival was significantly prolonged in the group that received it.
Systemic chemotherapy includes the following.
- GEM monotherapy: Show superiority over 5-FU monotherapy.
- S-1 monotherapy (GEST trial): Showed non-inferiority compared to GEM monotherapy.In the same study, GEM + S-1 combination therapy did not show superiority over GEM monotherapy and is not considered standard therapy.
The following three show superiority over GEM monotherapy, with the latter two regimens being the current standard first-line treatment.
- GEM +ErlotinibCombination therapy
- GEM + nab-PaclitaxelCombination therapy (MPACT study)
- FOLFIRINOX therapy:Oxaliplatin (L-OHP) +Irinotecan (CPT-11) +Revo Folinate(L-LV:Leucovorin) + 5-FU (ACCORD11 test)
"Maintenance therapy after chemotherapy including platinum anticancer drug in unresectable pancreatic cancer positive for BRCA mutation" is indicatedOlaparibIs licensed.
As second-line treatment, a fluoropyrimidine-based regimen is selected for GEM-based first-line treatment, and a GEM-based regimen is selected for fluoropyrimidine-based regimens such as FOLFIRINOX.Based on the results of the NAPOLI-1 study, nal-IRI (onibide 🄬) + 5FU / LV therapy is indicated as the second-line treatment when the GEM-based regimen is selected as the first-line treatment.
For locally advanced pancreatic cancer that does not metastasize to other organs but cannot be resected due to arterial infiltration, chemotherapy (5-FU or S-1 or GEM) and chemoradiotherapy are performed at the same time.
In addition, a method of performing laparotomy and irradiating the vicinity of the lesion intensively (intraoperative radiation therapy) may also be performed.
- Immunotherapy- ImmunotherapyIs in various waysImmune systemIt is a treatment method that activates and suppresses the progression of cancer.Tumor specificantigenAgainstCytotoxic T cellsAttempts have been made on methods such as inducing.Side effectsIs characterized by being relatively minor, and is also used in combination with other anticancer therapies.It is still under development and at some facilitiesClinical trialIt is done as.There are also private sector facilities that provide activated autologous lymphocyte transfer therapy, but this is not generally recommended due to the lack of evidence of therapeutic effect. Regarding "unresectable pancreatic cancer," the Japanese Society of Pancreatic Society states in its clinical practice guidelines that "when considering prolongation of survival for unresectable pancreatic cancer, it is proposed not to perform immunotherapy as a general clinical practice.".
- Supportive care- Supportive therapyIs a treatment given to alleviate the symptoms of cancer.It covers a wide range of areas, including pain relief, digestive symptoms relief, nutritional status improvement, ascites control, and mental distress care.Symptom control allows continued anti-cancer treatment, even after no effective anti-cancer treatment is availableQOLIt is possible to keep the life and fulfill the life.It is considered to be particularly important in pancreatic cancer because almost all patients die from the cancer.
Of pancreatic cancerprognosisIs very bad.5-year survival rateIs the lowest (5%) of cancers by site and is one of the most difficult cancers to treat.Although 2% of affected individuals (UICC TNM classification stages 1 and 2) are subject to surgical resection,Lymph nodeTransitionIs seen at an early stage, and even if excision is performed, about 7% will recur.
- On August 2019, 8, the United States Preventive Services Task Force (USPSTF) issued a statement that it does not recommend pancreatic cancer screening for asymptomatic adults after reviewing the benefits and harms of pancreatic cancer screening. did.
- Malignant tumor
- Courvoisier's sign
- IRE (irreversible electric drilling method)
- List of cancers
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- ^ "WHO Disease and injury country estimates". World Health Organization (2009). NovemberBrowse.
- ^ Cancer information service "Cancer registration / statistics" (Report). National Cancer Center.
- ^ a b "Easy Oncology" by Masanobu Kobayashi, Nankodo p106
- ^ Pancreatic adenocarcinoma NOW @ NEJM Retrieved April 2021, 4.
- ^ “Pancreatic cancer manifesting as Sister Mary Joseph nodule during follow up of a patient with type 2 diabetes mellitus: A case report”. Geriatr Gerontol Int 19 (4): 364. (April 2019). two:10.1111 / ggi.13602. PMID 30932308.
- ^ “Clinical and genetic characteristics of hereditary pancreatitis in Europe”. Clin. Gastroenterol. Hepatol. 2 (3): 252-61. (March 2004). PMID 15017610.
- ^ Familial Atypical Multiple Mole Melanoma Syndrome NIH Retrieved April 2021, 4.
- ^ (PDF) Committee on Diabetes and Cancer p384 Retrieved October 2021, 10.
- ^ Illustrated definitive edition pancreatic disease and the latest treatment & prevention method Supervised by Hideji Isaji
- ^ (PDF) Tokai University School of Medicine Department of Surgery Gastroenterological Surgery Toshihide Imaizumi Retrieved September 2021, 9.
- ^ Distinct methylation levels of mature microRNAs in gastrointestinal cancers nature communications Retrieved April 2021, 4.
- ^ Pancreas practice guidelines 2016 editionKanahara Publishing. (2016) Retrieved October 2019, 10.
- ^ "Pancreatic cancer screening is "not recommended" by the U.S. Expert Committee”. Mainichi Shimbun (December 2019, 8). NovemberBrowse.
- Japan Pancreatic Society Pancreatic Cancer Practice Guideline Revision Committee (ed.)Pancreatic Cancer Practice Guidelines 2019 5th Edition Kanahara Publishing 2019/07/20 ISBN 978-4-307-20400-2
- (PDF) Japanese Pancreatic Society
- (PDF) Japan Pancreas Society Kanahara Publishing 2015
- Scientifically Based Pancreatic Cancer Practice Guidelines 2013 (3rd Edition) Japanese Pancreatic Society
- Scientifically Based Pancreatic Cancer Practice Guidelines 2009 (2rd Edition) [Japanese Pancreas Society (09)] (Minds Medical Information Service）
- Scientifically Based Pancreatic Cancer Practice Guidelines 2006 (First Edition) [Japan Pancreas Society (06)] (Minds Medical Information Service)
- Judgment criteria / guidelines(Japanese Pancreatic Society）
- Pancreatic cancer(Japanese Society of Hepatobiliary and Pancreatic Surgery）
- About pancreatic cancer
- Pancreatic Cancer National Advocacy Day --NPO Pancan Japan Pancreatic Cancer Action Network
- Basic knowledge of pancreatic cancer --Medical archive