Treatment paths for pancreatic cancer are heavily influenced by the stage at which it is discovered. The staging process categorizes the disease based on its progression, which dictates the therapeutic strategy. This article explains a specific stage known as locally advanced pancreatic cancer and what this diagnosis means for patients and their families.
Defining Locally Advanced Pancreatic Cancer
Locally advanced (Stage III) pancreatic cancer occurs when a tumor extends beyond the pancreas to involve nearby tissues and major abdominal blood vessels. This involvement is a defining characteristic that distinguishes it from other stages. It also informs the initial treatment strategy.
The term “locally advanced” signifies the cancer has grown into the surrounding area but has not metastasized (spread) to distant organs like the liver or lungs. This separates it from metastatic (Stage IV) disease, which has a different treatment approach and prognosis. Approximately one-third of individuals with pancreatic cancer are diagnosed at this stage.
This stage is distinct from “resectable” pancreatic cancer, where the tumor is confined to the pancreas and can be surgically removed. Locally advanced tumors are considered “unresectable” at diagnosis due to their proximity to or envelopment of blood vessels. Attempting to remove such a tumor carries a high risk of complications and would likely not remove all cancerous tissue.
The degree of tumor contact or encasement around specific blood vessels determines its classification as locally advanced. This involvement prevents surgeons from achieving clean margins, a requirement for a successful cancer operation. The primary blood vessels of concern include:
- The superior mesenteric artery
- The celiac axis
- The hepatic artery
- The superior mesenteric vein
The Diagnostic and Staging Process
Diagnosing locally advanced pancreatic cancer relies on advanced imaging to visualize the tumor and its relationship with surrounding structures. High-resolution, multiphase computed tomography (CT) scans are the standard tool. These scans provide cross-sectional images of the abdomen, showing the pancreas, tumor size, and its interaction with major blood vessels.
Physicians may also use an endoscopic ultrasound (EUS) for a more detailed view of the pancreas and tumor. This procedure involves passing a tube with an ultrasound probe through the mouth into the stomach and small intestine. An advantage of EUS is the ability to perform a fine-needle aspiration biopsy, where a tissue sample is collected to confirm the presence of cancer cells.
A blood test for the tumor marker CA 19-9 is also performed. While not specific enough for diagnosis alone, this protein can be elevated in people with pancreatic cancer and serves as a baseline measurement. Tracking CA 19-9 levels helps doctors monitor the disease and assess treatment response.
Primary Treatment Approaches
Treatment for locally advanced pancreatic cancer begins with neoadjuvant therapy, which is administered before any consideration of surgery. The goals are to shrink the tumor away from the entangled blood vessels and to address any cancer cells that may have escaped the primary tumor. This systemic treatment is intended to control the disease both locally and throughout the body.
Systemic chemotherapy is the initial component of treatment for most patients. Combination chemotherapy regimens are used to maximize their effect on cancer cells. A common regimen is FOLFIRINOX, a combination of four drugs administered intravenously in cycles to stop cancer cells from growing and dividing.
Following chemotherapy, radiation therapy may be recommended to deliver a focused dose of high-energy rays to the tumor. This helps destroy remaining cancer cells, further shrink the tumor, and prevent local recurrence. Advanced techniques like Stereotactic Body Radiation Therapy (SBRT) deliver higher radiation doses over a shorter period.
The decision to use chemotherapy alone or with radiation is tailored to the individual. Factors include the patient’s overall health, tumor characteristics, and the cancer’s response to initial chemotherapy. The response to neoadjuvant therapy is monitored with follow-up imaging scans.
The Role of Surgery
Surgery is not the first line of treatment for locally advanced pancreatic cancer. The goal of the initial neoadjuvant therapy is to make a previously impossible surgery a potential option. This is called “conversion surgery,” where treatment converts an unresectable tumor into a resectable one.
The possibility of surgery is re-evaluated after several months of neoadjuvant therapy. Imaging scans must show the tumor has shrunk and is no longer in contact with the blood vessels. There must also be no evidence of cancer growth elsewhere, confirming the disease has remained localized.
A patient’s overall physical health is another consideration, as pancreatic surgery is a major operation requiring a certain level of fitness. The medical team assesses a patient’s strength and ability to recover before recommending the procedure. If all conditions are met, the patient may become a surgical candidate.
The most common operation for tumors in the head of the pancreas is a pancreatoduodenectomy, or Whipple procedure. This complex surgery removes the head of the pancreas, a portion of the small intestine, the gallbladder, and part of the bile duct. The goal is to remove all visible tumor with clear margins.
Prognosis and Disease Management
The outlook for locally advanced pancreatic cancer has improved with modern treatment strategies. Neoadjuvant therapy allows a subset of patients to become eligible for surgery, which offers the best chance for long-term survival. The prognosis for those who undergo successful conversion surgery is significantly better than for those whose tumors remain unresectable.
If cancer does not respond enough to neoadjuvant therapy to allow for surgery, treatment shifts to long-term disease control. Ongoing chemotherapy or other systemic therapies are used to keep the cancer from growing and spreading. The goal is to manage the cancer as a chronic condition while maintaining quality of life.
Palliative care is a component of disease management for all patients, regardless of surgical eligibility. It focuses on managing symptoms like pain, nausea, and nutritional difficulties. This care can be provided alongside active cancer treatment to improve comfort and overall well-being.
Clinical trials are another avenue for patients, offering access to new treatments not yet widely available. Participation provides an opportunity to receive a potentially more effective therapy. It also contributes to advancing medical knowledge in the fight against this disease.