The treatment of cancer patients has become complex as a result of the introduction of new therapies and insights into how to use these therapies. Quite often the true benefit of new therapies is unknown in relation to the current standard of care. Moreover, the one-size-fits-all approach is being replaced by personalized treatments based on not only molecular markers but also performance status. In addition to these factors, the treatment of most gastrointestinal cancers involves fighting battles on two fronts—the systemic battle and the local battle. The integration of systemic treatments with localized treatments such as surgery and radiotherapy requires an integrated team approach. As a result of these factors, we feel the optimal management of cancer in the modern era is through a multidisciplinary team (MDT) approach that involves at the very least medical oncology, radiation oncology, surgery, pathology/cytopathology, diagnostic imaging, pain management, and social services. This chapter is a presentation of the benefit of a multidisciplinary approach as it applies to the focus of our group—pancreatic cancer. It should be noted, however, that the concepts of this chapter apply to all gastrointestinal cancers.
Pancreatic cancer is the third leading cause of cancer-related deaths despite having the eleventh most common incidence of all malignancies in the United States. It is estimated that in the year 2016 approximately 53,070 patients in the United States were diagnosed with pancreatic cancer and that 41,780 were died from the disease.1 The median age of diagnosis in the United States is 72 years, and over 66% of patients are diagnosed after the age of 65.2 There is a slight predominance in African Americans and Caucasians as opposed to Hispanics and Asians.3
Most patients with pancreatic adenocarcinoma present late in the course of disease, as early pancreatic cancer is often silent.4 Patients commonly present with signs and symptoms of biliary obstruction including jaundice, pruritus, light- or clay-colored stools, dark urine, and scleral icterus. Occasionally, pancreatitis and cholangitis may be the presenting symptoms of this malignancy.5 It should be recognized that these signs and symptoms are common for cancer of the head of the pancreas and that pancreatic body/tail lesions are often more advanced at presentation. Involvement of the celiac nerve plexus may result in epigastric abdominal pain, classically presenting as a dull pain that radiates to the mid-back. Early bowel or stomach obstruction may result in early satiety, nausea, vomiting, and/or dyspepsia. Some patients with pancreatic cancer present with diabetes mellitus, and diabetes can be present for several years before a diagnosis is established. Migratory thrombophlebitis is an uncommon, but well-recognized, presenting sign in this malignancy.6
Cross-sectional imaging can be used to characterize pancreatic masses and a tissue diagnosis can often be obtained through endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). In general, pancreatic adenocarcinomas tend to be hypoattenuating on venous-phase CT, while ...