It is reassuring to note that Mr Greenway reports the treatment of a series of patients with pancreatic cancer, where histological diagnosis was achieved in only 28.8%1. Recently, we have retrospectively reviewed 13 patients with localised pancreatic cancer treated here with chemoradiation between February 1994 and July 1997. In our series histological diagnosis was achieved in 46.1%. All of our patients received 45Gy external beam radiotherapy in 25 fractions over 33 days together with 5FU 350mg/m2 and folinic acid 20mg/m2, 1 hour prior to the radiotherapy during the first and last five days of treatment. Maximal toxicity was noted as WHO grade 2 nausea / vomiting in 15%. 5 (45.4%) had image evidence of response. The median symptom free interval was 12 months. Excluding two patients who died within 6 weeks of completing treatment, 45.4 % (5/11) are still alive, 3 having no evidence of disease recurrence to date, 18, 18 and 21 months after diagnosis.
Histological diagnosis is normally considered imperative prior to radiation or cytotoxic treatment but given the above results, we have felt uncomfortable delaying effective chemoradiation for a positive histological diagnosis and like Greenway, rely on a constellation of signs and symptoms. The pancreas is difficult to image by conventional means, the gold standard still being spiral CT with intravenous and oral contrast2; small tumours are often more apparent at ERCP, especially those located in the head of the pancreas. 11 of our patients had assessable disease on CT, the remainder were confirmed visually at ERCP.
Endoscopic, ultrasound-guided fine needle aspirates have been reported to yield histological proof of malignancy in 53% 3 although we understand that in practice, this procedure can make stent insertions, with consequent symptom relief, impossible. In addition, a negative result cannot exclude malignancy and the smaller, potentially more curable lesions are those most likely to be missed. However, cytological examination of pancreatic duct brushings or catheter aspiration (during ERCP) can improve the rates of positive diagnosis, up to 90% if p53 immunocytochemistry is employed 4. The tumour associated antigen, CA19-9 can also be a useful adjunct to diagnosis, being elevated in 70-80% of patients with adenocarcinoma of the pancreas5.
We currently believe that we should continue to offer chemoradiation, if necessary on the basis of a constellation of signs and symptoms, but would like to urge all endoscopists to at least attempt pancreatic duct brushings and CA19-9 estimation prior to oncology referral. We also look forward to incorporating flutamide into our management of pancreatic cancer, preferably in the setting of an appropriate clinical trial.
Dr. Marcia Hall, Senior Registrar, Medical Oncology
Dr. Rob Glynne Jones, Consultant in Clinical Oncology
Mount Vernon Hospital Cancer Centre
1. Greenway BA. Effect of flutamide on survival in patients with pancreatic cancer: results of a prospective randomised, double blind, placebo controlled trial. BMJ
1998;316:1935-8 (27 June)
2. Wyatt SH, Fishman EK. Spiral CT of the pancreas. Semin Ultrasound CT MR 1994;15:122-132.
3. Binmoeller KF, Thus R, Rathod V, Hanke P, Brand B, Jabusen HC, Soehendra N. Endoscopic ultrasound-guided, 18-gauge, fine needle aspiration biopsy of the pancreas using a 2.8mm channel convex array echoendoscope. Gastroinestinal Endoscopy 1998;47(2):121-7
4. Ishimaru S, Itoh M, Hanada K, Tsuchida A, Iwao T, Kajiyama G. Immunocytochemical detection of p53 protein from pancreatic duct brushings in patients with pancreatic carcinoma. Cancer 1996;77(11) :2233-9.
5. Steinberg WM, The clinical utility of the CA19-9 tumour associated antigen. Am J Gastroenterol 1990; 85:350-5.
Competing interests: No competing interests