Introduction
Pancreatic carcinoma, manifesting as occult and rapid onset, is the tumor with the worst prognosis among malignant abdominal tumors. It often occurs among the elderly, and the incidence in developed countries is higher than that in developing countries. With the improvement of living standards in China and changes in diet structure in recent years, the incidence of pancreatic carcinoma has shown an upward trend and the disease now tends to occur at a younger age. The incidence of pancreatic carcinoma has risen from 20th to 12th among cancers.
Jaundice and abdominal pain are the most common among the first symptoms of pancreatic carcinoma, followed by weight loss, upper abdominal fullness, back pain, fatigue, as well as individual heat.
Treatments
1.Surgery
Based on cancer locations, surgery can be broadly divided into pancreaticoduodenectomy, distal pancreatectomy, and total pancreatectomy. On the whole, pancreatic surgery is a major operation and requires high levels of technology and surgeon experience, as well as integrative treatments before and after surgery. If possible, surgery should be carried out in hospitals with extensive pancreatic surgery experience.
For patients not suitable for radical resection due to tumor or health reasons, appropriate surgical intervention might provide significant effect in prolonging survival and improving quality of life. In this case, the common surgical interventions include gastroenterostomy and choledochojejunostomy. It should be emphasized that with the advancement of medical science the technology of catheter and stent is increasingly widely being used and the performance of open palliative choledochojejunostomy has been significantly reduced for simple biliary obstruction.
2.Radiotherapy
The majority of pancreatic carcinomas are cancers occurring on the pancreatic ductal epithelium, with infiltrative growth, high degree of malignancy, poor prognosis, and higher postoperative recurrence rates. Radiotherapy is suitable for patients with localized lesions but has poor clinical efficacy for patients with metastasis. Because the pancreas is deeply located, the sensitivity of pancreatic carcinoma to radiation is lower; dosage required to kill the cancer cells is high; and radiosensitivity of peripancreatic organs such as liver, kidney, intestines and stomach, spinal cord, and others is higher than the pancreas and hence they are susceptible to radiation damage. As a result, radiotherapy is not regarded as the primary treatment clinically and is mainly applied for inoperable integrative treatments of locally advanced pancreatic carcinoma and integrative treatments of postoperative residual cancer or recurrence, as well as palliative reduction treatment of advanced pancreatic carcinoma. In recent years, with the advancement of radiotherapy it is applied in some cases as neoadjuvant radiotherapy before surgery for improving surgical treatment or increasing the resection rate.
3.Chemotherapy
Pancreatic carcinoma has poor sensitivity to chemotherapy, so chemotherapy is generally not preferred nor is it applied alone. Chemotherapy is mainly applied as neoadjuvant or adjuvant therapy, or for locally advanced unresectable and metastatic pancreatic carcinoma. There is evidence that pancreatic carcinoma postoperative adjuvant chemotherapy may extend survival. Adjuvant chemotherapy for pancreatic carcinoma should begin about 1 month after radical resection, and its purpose is to prolong survival, improve quality of life, and increase the effects of other treatments. It can also be applied as palliative chemotherapy for patients who did not receive radical treatment. In recent years, there have been more applications of neoadjuvant chemotherapy with the purpose of preoperatively improving surgical outcomes or increasing the resection rates.
For pancreatic carcinoma, the commonly used chemotherapy drugs are gemcitabine or TS-1 (S1) used alone or in combination with 5-fluorouracil, TS-1, oxaliplatin, and so on.
4.Hyperthermia
Due to its insidious onset and poor prognosis, combined therapy in the treatment of pancreatic carcinoma is particularly important. Hyperthermia, as an emerging anticancer therapy, in combination with existing treatments provides a new approach for the treatment of pancreatic carcinoma, achieves clinically positive effects, and plays an important role in the integrative treatments of pancreatic carcinoma. For pancreatic carcinoma that cannot be completely removed by operation, interstitial high frequency electromagnetic wave coagulation therapy can be carried out, which includes interstitial microwave therapy and interstitial RF coagulation treatment. Interstitial microwave therapies for pancreatic carcinoma mainly include microwave coagulation therapy, intraoperative microwave coagulation therapy, and ultrasound-guided microwave coagulation therapy. For patients with advanced pancreatic carcinoma, clinical studies have shown that out-of-body high-intensity focused ultrasound hyperthermia combined with chemotherapy has a positive effect. In addition, in recent years studies have shown that intraperitoneal hyperthermic perfusion chemotherapy combined with external high frequency diathermy for the treatment of advanced, unresectable pancreatic carcinoma also has a satisfactory clinical outcome.
5.Chelation Detoxification Therapy
Chelation detoxification therapy can effectively remove toxins from the body and improve immune function and also reduce the side effects of chemotherapy and enhance chemosensitivity. The simultaneous application of chelation detoxification with hyperthermia can have a synergistic effect. The application of chelation detoxification can have inhibitory effects on tumor recurrence and metastasis, can repair the damage in various tissues and organs, and can improve cell functions.
6.Medical Ozone Therapy
Treating early pancreatic carcinoma patients with medical ozone therapy can improve the immune system and inhibit cancer development. Medical ozone therapy can incorporate major autohemotherapy, vein medical ozone saline, EBOO, medical ozone acupoint injection, and so on. Different methods are applicable to patients with different physical conditions, but the principles behind the therapeutic effects are the same.
7.Traditional Chinese Medicine
The syndrome of qi stagnation and blood stasis can be seen in the early stages of pancreatic carcinoma, and the prescriptions recommended are Xuefu Zhuyu Decoction and modified Yueju Pill. For the syndrome of deficiency of stomach yin, the prescriptions recommended are Yiguan Decoction and modified Biejiajian Pill. The syndrome of splenic asthenia and accumulation of dampness is more common in advanced pancreatic carcinoma, and the prescription recommended is modified Xiangsha Liujunzi Decoction. For the syndrome of excessive dampness, heat, and toxin, the prescription recommended is modified Yinchenhao Decoction. For the syndrome of qi and dampness stagnation, the prescriptions recommended are Erchen Decoction and modified Pingwei Powder. For the syndrome of yin deficiency and toxic stasis, the prescriptions recommended are Yiguan Decoction and Biejiajian Pill.
8.Acupuncture
Early pancreatic carcinoma mainly manifests the syndromes of qi stagnation and blood stasis as well as spleen–stomach dampness heat. We should focus on clearing heat and eliminating dampness, as well as regulating qi to dissipate blood stasis.
The syndrome of medium-advanced pancreatic carcinoma is mainly spleen and kidney deficiency, and the therapeutic principle should focus on invigorating the spleen and nourishing kidneys.
9. Medicated Diet, Nutrition, and so on
Medicated diet is mainly for the treatment of early pancreatic carcinoma; it focuses on increasing appetite and supplementing nutrition. Digestive enzymes and megestrol acetate can be given to aid digestion and improve appetite. Medium-advanced patients who can eat can receive oral administration, which can be appropriately supplemented with amino acids, and so on. If there is obstruction, total parenteral nutrition can be given. If the condition permits, it is best to utilize a fistula to give nutritional meals. Combine with other therapies to prolong survival time and improve quality of life. At the same time, give qigong, music therapy, as well as mental therapy to relax the patient and to relieve pain.
10.Others
In recent years, sorafenib, erlotinib, cetuximab, bevacizumab, and other targeted therapy drugs have been tentatively applied for pancreatic carcinoma, but the effects are far from satisfactory and we still need further exploration. Qigong, tai chi, music, and mental therapy can adjust the patient’s psychology, contributing to the treatment of the disease.
Typical Case
Male patient, was diagnosed in Toronto Hospital, Canada by CT scan Sept 2006 with pancreatic carcinomas, a 5.7cm×3.6cm×4cm mass in the tail of the pancreas. When partial pancreatectomy was carried out in the Canadian hospital, intraoperative multiple lymph nodes in the abdominal cavity with gastric wall invasion were found. No further postoperative treatment was given. Patient was followed up six months before admission to Clifford Hospital. Abdominal CT showed neoplasms near the left renal artery as well as multiple liver metastases consistent with pancreatic carcinoma accompanied with lymph node metastasis and liver metastasis. Patient exhibited recurrent abdominal dull pain accompanied with anorexia, thin physique, and weight loss of 8 kg. He came to Clifford Hospital from Canada for further treatment.
Diagnosis: postoperative pancreatic carcinoma and recurrence, accompanied with lymph node metastasis and liver metastasis.
Integrative treatment prescription: when patient was admitted, his symptoms were poor appetite, weight loss and pain. Specialists concluded that immediate treatment should focus on pain management and nutrition to build patient’s confidence to fight cancer. TCM and acupuncture helped to relieve pain. Trypsin and a combination of medicated diet were added for the replenishment of fat emulsions, amino acids. Stringent effort was made to boost his nutrition for cancer treatment. Whole body hyperthermia was given in combination with chelation and detoxification therapy, alternating with EBOO. (As there was postoperative metal remnants in patient’s abdominal cavity, he was not suitable for local hyperthermia.)
Treatment outcome: after patient was hospitalized for 45 days of integrative treatment, his mental state improved, pain relieved, regained appetite, body weight increased to 56kg, and his quality of life was significantly improved. The KPS was 90. Patient was reassessed by abdominal CT, which showed no recurrence of lesions in the residual pancreas, and at the head of the pancreas the number of multiple intrahepatic low-density lesions had decreased. Patient continued to adhere to outpatient treatment, during which he received chelation and detoxification therapy twice a week, medical ozone therapy once a week, and whole hyperthermia once a week. Patient was followed up after 5 months. Abdominal CT showed postoperative liver metastases of pancreatic carcinoma. Compared with the previous CT, the changes were observed as follows: The number of liver metastases had decreased and the volume was also reduced; blood routine reexamined was normal. Liver function: alkaline phosphatase (ALP) 135U/L and r-GT 99U/L. Tumor markers: CEA 37.5ng/ml, CA-199 21.03 U/ml, and the rest were normal. Patient lived a normal life without obvious discomfort and remained on a weekly outpatient treatment program.
