How is hyperbilirubinemia (elevated bilirubin levels) in metastatic pancreatic cancer best managed?

From the Guidelines

Hyperbilirubinemia in metastatic pancreatic cancer is best managed by relieving biliary obstruction through endoscopic or percutaneous interventions, with the preferred first-line approach being endoscopic retrograde cholangiopancreatography (ERCP) with placement of a metal biliary stent, as recommended by the American Society of Clinical Oncology clinical practice guideline 1.

Key Considerations

• The goal of treatment is to improve quality of life by relieving pruritus, reducing jaundice, enabling chemotherapy administration, and potentially extending survival.
• The choice of intervention should be individualized based on the patient's disease extent, performance status, life expectancy, and local expertise.
• Metal stents are preferred over plastic stents due to their longer patency, as stated in the guideline 1.

Alternative Interventions

• If ERCP is not feasible, percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound-guided biliary drainage (EUS-BD) are appropriate alternatives.
• For patients with extensive disease or poor performance status, medical management with corticosteroids (dexamethasone 4-8 mg daily) may help reduce inflammation around the biliary tract, as suggested by the guideline 1.

Adjunctive Measures

• Adequate hydration and nutritional support are essential adjunctive measures to improve patient outcomes.
• Surgical bypass (hepaticojejunostomy) is rarely used in the metastatic setting due to high morbidity and prolonged recovery, as noted in the guideline 1.

Chemotherapy Considerations

• FOLFIRINOX and gemcitabine plus NAB-paclitaxel are the two frontline regimens for metastatic pancreatic cancer management, as recommended by the American Society of Clinical Oncology clinical practice guideline 1.
• The choice of chemotherapy regimen should be based on the patient's performance status, life expectancy, and local expertise.

From the Research

Hyperbilirubinemia in Metastatic Pancreatic Cancer

• Hyperbilirubinemia is a common condition in patients with advanced pancreatic adenocarcinoma, occurring both at diagnosis and throughout disease evolution 2.
• The development of hyperbilirubinemia determines chemotherapy treatment selection, making it a relevant condition to consider in the management of pancreatic cancer patients 2.

Causes and Treatment of Hyperbilirubinemia

• The main causes of hyperbilirubinemia in pancreatic cancer patients include malignant biliary obstruction, which can be treated with endoscopic biliary stent placement or percutaneous biliary drainage 3, 4.
• The choice of treatment for malignant biliary obstruction depends on the clinical scenario, including the patient's life expectancy and the presence of resectable disease 3.
• For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy, and endoscopic therapy or surgical approach can be used to treat concomitant duodenal and biliary obstruction 3.

Management of Hyperbilirubinemia in Metastatic Pancreatic Cancer

• The management of hyperbilirubinemia in metastatic pancreatic cancer patients involves considering the underlying aetiology of hyperbilirubinemia and the metabolisation routes of cytotoxic drugs 5.
• An initial dose reduction of chemotherapy with nab-paclitaxel/gemcitabine may be necessary based on the total bilirubin level in patients with biliary obstruction or extensive liver metastasis 5.
• There is limited evidence for the use of chemotherapy in patients with hyperbilirubinemia, and current clinical evidence and recommendations for treatment are based on expert opinion and limited studies 5, 2.

Comparison of Endoscopic and Percutaneous Biliary Drainage

• A randomized controlled study compared endoscopic versus percutaneous biliary drainage for resectable pancreatic head cancer with hyperbilirubinemia and found that percutaneous biliary drainage provided more short-term advantages over endoscopic stenting before pancreaticoduodenectomy 4.
• The study found that patients who underwent percutaneous transhepatic biliary drainage (PTD) had fewer morbidities and shorter hospital stay compared to those who underwent endoscopic retrograde cholangiopancreatography (ERCP) 4.