From the Guidelines
The primary treatment for undifferentiated ductal carcinoma, specifically pancreatic ductal adenocarcinoma, is surgical resection whenever possible, as this offers the best chance for long-term survival, with the most recent and highest quality study 1 supporting this approach.
Treatment Overview
The treatment of pancreatic ductal adenocarcinoma (PDAC) depends on the stage and resectability of the tumor.
- For resectable tumors, a pancreaticoduodenectomy (Whipple procedure) is typically performed for tumors in the head of the pancreas, while distal pancreatectomy is used for tumors in the body or tail.
- Surgery is often followed by adjuvant chemotherapy, commonly with FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) or gemcitabine plus capecitabine for 6 months to reduce recurrence risk, as recommended by 1.
- For borderline resectable disease, neoadjuvant chemotherapy and/or radiation may be used to downstage the tumor before attempting surgery, with the goal of achieving an R0 resection, as suggested by 1 and 1.
Adjuvant Chemotherapy
Adjuvant chemotherapy is an essential component of the treatment plan for resected PDAC, with the combination of gemcitabine and capecitabine being a preferred option, as shown in the ESPAC-4 study 1 and recommended by 1.
- The choice of adjuvant chemotherapy regimen depends on the patient's performance status, comorbidities, and ability to tolerate treatment toxicities.
Neoadjuvant Therapy
Neoadjuvant therapy is increasingly being used in the treatment of PDAC, particularly for borderline resectable and locally advanced disease, as discussed in 1.
- The goal of neoadjuvant therapy is to downstage the tumor, making it more amenable to surgical resection, and to assess the tumor's response to treatment.
Systemic Chemotherapy
For patients with advanced PDAC, systemic chemotherapy is the mainstay of treatment, with regimens like FOLFIRINOX or gemcitabine plus nab-paclitaxel (Abraxane) used as first-line options, as recommended by 1.
- The choice of chemotherapy regimen depends on the patient's performance status, comorbidities, and ability to tolerate treatment toxicities.
From the FDA Drug Label
- 4 Pancreatic Cancer Gemcitabine Injection is indicated as first-line treatment for patients with locally advanced (nonresectable Stage II or Stage III) or metastatic (Stage IV) adenocarcinoma of the pancreas. Gemcitabine Injection is indicated for patients previously treated with fluorouracil.
The primary treatment for undifferentiated ductal carcinoma, specifically pancreatic ductal adenocarcinoma, is Gemcitabine Injection as a first-line treatment for patients with locally advanced or metastatic adenocarcinoma of the pancreas 2.
- Key points:
- Indicated for locally advanced (nonresectable Stage II or Stage III) or metastatic (Stage IV) adenocarcinoma of the pancreas
- Also indicated for patients previously treated with fluorouracil
- Used as a first-line treatment 2
From the Research
Treatment Options for Undifferentiated Ductal Carcinoma
- The primary treatment for undifferentiated ductal carcinoma, specifically pancreatic ductal adenocarcinoma, includes chemotherapy regimens such as FOLFIRINOX (fluorouracil, leucovorin, irinotecan, and oxaliplatin) and gemcitabine plus nab-paclitaxel (GA) 3, 4, 5, 6.
- FOLFIRINOX has been associated with higher rates of RECIST partial response and subsequent pancreatectomy compared to GA, but overall survival rates are similar 3.
- Gemcitabine is a commonly used chemotherapeutic drug for pancreatic cancer, but chemoresistance poses a significant challenge 4.
Adjuvant Treatment
- Adjuvant treatment, including chemotherapy and radiation therapy, is used to target early micrometastatic disease in patients who have undergone surgical resection of pancreatic ductal adenocarcinoma 7.
- Combination chemotherapy is favored for adjuvant treatment, and neoadjuvant chemoradiation therapy is also being explored 7.
Comparison of Treatment Regimens
- A retrospective analysis of prospectively collated data from the PURPLE pancreatic cancer registry found that median overall survival was comparable between patients receiving first-line Gemcitabine/Nab-Paclitaxel and those receiving FOLFIRINOX 6.
- The choice of first-line chemotherapy regimen did not significantly impact overall survival, but FOLFIRINOX was associated with delayed progression 6.
- Patient-derived cell lines have been used to compare the sensitivity of pancreatic ductal adenocarcinoma cells to FOLFIRINOX and gemcitabine plus paclitaxel, with some cell lines exhibiting optimal sensitivity to one regimen over the other 5.