Pancreatic Cancer·Bile Duct Cancer

Pathophysiology and clinical classification: Over 90% of pancreatic cancers originate from ductal cells as pancreatic ductal adenocarcinoma (PDAC), and bile duct cancers are epithelial malignancies arising from intrahepatic bile ducts, hilar bile ducts (Klatskin tumors), distal bile ducts, and the gallbladder. The pancreas and bile ducts are anatomically located deep in the retroperitoneum and are surrounded by major large vessels and nerve networks, such as the celiac artery, superior mesenteric artery (SMA), superior mesenteric vein (SMV), and portal vein (PV), making tumor invasion and early metastasis very frequent.

Domestic and international epidemiological statistics:

Ranked 8th in cancer incidence and 4th in cancer mortality (pancreatic cancer) in Korea.

According to national cancer registry statistics, the 5-year relative survival rate for pancreatic cancer is about 15.9%, and for biliary cancer only about 28.5%. However, for early-stage patients who successfully undergo curative resection (R0 resection) and complete adjuvant chemotherapy, the 5-year survival rate significantly increases to over 30–40%, making early aggressive multidisciplinary treatment the key factor in determining survival.

Nonspecific early symptoms and risk of misdiagnosis: Early pancreatic and biliary cancer have no clear symptoms and are similar to general gastritis or other gastrointestinal diseases, with symptoms like epigastric pain, indigestion, and loss of appetite, leading to many cases where months are wasted with simple gastrointestinal medication prescriptions. Especially, if back pain (radiating pain) or unexplained rapid weight loss (over 10%) occurs, there is a high risk that the tumor has already invaded the retroperitoneal nerve plexus.

Emergencies of obstructive jaundice and acute cholangitis: Patients with pancreatic head cancer or cholangiocarcinoma experience jaundice with yellowing of the eyes and skin, gray stools, dark brown urine, and pruritus due to tumor compression of the bile duct. If infection occurs in retained bile leading to acute obstructive suppurative cholangitis (AOSC), death from septic shock may occur within days, making immediate biliary drainage essential.

Warning for newly developed diabetes: For individuals aged 50 or older, if diabetes is suddenly diagnosed without a family history, or if previously well-controlled diabetes deteriorates rapidly without a specific cause, this may be an early precursor sign of pancreatic cancer, and detailed pancreatic imaging should be conducted.

Pancreas Protocol Multi-Phase Contrast CT (Pancreas Dynamic CT):

Perform contrast-enhanced thin-slice CT to precisely evaluate the low-density pattern of the pancreatic mass in the early arterial and effective parenchymal phases and the angle of contact with major surrounding vessels (SMA, SMV, celiac artery, portal vein) (less than 180 degrees contact vs excessive infiltration) using three-dimensional reconstruction.

Magnetic Resonance Cholangiopancreatography (MRCP / 3.0T MRI):

Non-invasively visualize dilation, stricture, and defects of the pancreatic and bile ducts without contrast agent to determine the intrahepatic infiltration range of bile duct cancer and the malignancy of intraductal papillary mucinous neoplasms (IPMN) of the pancreas.

Endoscopic ultrasound (EUS) and histological confirmation (EUS-FNA/FNB):

Press an ultrasound probe against the wall of the stomach and duodenum to capture pancreatic tumors smaller than 1 cm, and perform core tissue biopsy (FNB) of the tumor using a special biopsy needle under real-time ultrasound guidance to simultaneously conduct molecular pathology and genomic testing.

Endoscopic retrograde cholangiopancreatography (ERCP) and cholangioscopy (SpyGlass):

Insert a catheter through the duodenal papilla to perform bile cytology at the site of biliary stricture and place a plastic or self-expandable metal stent (SEMS) for jaundice relief.

Step 1: Acute complication control and precise staging determination (Day 1 ~ Day 3)

In cases accompanying obstructive jaundice, urgent ERCP biliary stent insertion is performed to stabilize jaundice levels (bilirubin). Pancreatic protocol CT, MRI (MRCP), PET-CT, and EUS-FNB biopsy are performed concurrently.

Step 2: Evaluate vascular invasion and confirm treatment plan at the multidisciplinary tumor board (Day 4 ~ Day 7)

Resectable: Immediate [radical resection] pathway.

Borderline resectable (BRPC) / Locally advanced (LAPC): Surgery is expected to have positive resection margins due to major vascular invasion, so establish the path: [FOLFIRINOX or GnP neoadjuvant chemotherapy for 4–8 cycles] ➔ [downstaging curative surgery after response evaluation].

Step 3: Precision surgery and intensive care in the ICU (Week 2 ~ Week 3)

Head tumors: Pylorus-preserving pancreaticoduodenectomy (PPPD) or standard Whipple procedure (with SMV/portal vein resection and artificial vascular reconstruction if necessary).

Body and extremity tumors: Laparoscopic/robotic anterior and posterior radical distal pancreatectomy (RAMPS) and splenectomy

Postoperative pancreatic fluid leakage (POPF) monitoring and intensive chest-abdominal drainage management.

Stage 4: Adjuvant chemotherapy and digestive/endocrine rehabilitation (Week 5 ~)

Completion of 6 months of adjuvant chemotherapy (mFOLFIRINOX, etc.) based on final pathology results.

Prescription of digestive enzyme (Pancreatin) due to exocrine pancreatic insufficiency and precise insulin therapy management by dedicated endocrinology for post-surgical diabetes.