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Palliative Management of Pancreatic Cancer

  • Milind Javle
  • Michael Fisch
Reference work entry

Abstract:

The results of anticancer therapy are suboptimal for pancreatic cancer and palliation of symptoms is an important goal at all stages of this disease. Pain, depression, cachexia, ascites, jaundice, thrombosis and gastroparesis occur commonly and present a considerable burden on the patient and the caregivers and require inter-disciplinary management. A comprehensive assessment which includes clinical assessment and the use of quality of life instruments are invaluable as is the establishment of treatment goals early on the course of this disease. Painless jaundice is commonly associated with cancer of the pancreatic head. Its palliation can be achieved surgically in resectable cases and with a biliary stent in patients with locally advanced or metastatic disease. Metallic stents are preferred in unresectable tumors. However, cholangitis, stent occlusion and cholecystitis are complications. Pain control is optimally achieved with the use of oral analgesics; however, tolerance, constipation, sedation are common and require close monitoring. Neurolytic celiac plexus blocks have not been shown to be superior to systemic analgesics and are best utilized for instances wherein oral opioids are ineffective. Poor symptom control, social support and advanced stage are all associated with higher risk of depression, which can be treated in a similar manner as in the non-cancer setting. Unrelenting nausea, early satiety and weight loss, in the absence of mechanical gastric outlet obstruction should alert the providers as to the possibility of gastroparesis, an under-recognized problem in gastrointestinal oncology. Prokinetic agents are beneficial for most of these patients, but in extreme cases, gastrostomy or jejunostomy is required. Cachexia is one of the most challenging aspects of care for pancreatic cancer, and occurs irrespective of the cancer stage. Cachexia requires nutritional support, orexigenic agents, diabetic control and enzyme supplementation. Malignant ascites can be investigated with ascitic-serum albumin gradient; a high gradient in the absence of positive cytology suggests portal vein thrombosis, which is treatable with anticoagulants. Recent data indicate that peripherally-acting opioid receptor antagonists induce laxation and therefore represent a significant advance in the management of opioid-induced constipation. These and other commonly occurring palliative issues in pancreatic cancer are discussed using the case study format.

Keywords

Pancreatic Cancer Palliative Care National Comprehensive Cancer Network Portal Vein Thrombosis Pancreatic Cancer Patient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Merchant N, Berlin J: Past and future of pancreas cancer: are we ready to move forward together? J Clin Oncol 2008;26(21):3478–3480.CrossRefPubMedGoogle Scholar
  2. 2.
    Moore MJ, Goldstein D, Hamm J, et al.: Erlotinib plus gemcitabine compared with gemcitabine alone in patients with advanced pancreatic cancer: a phase III trial of the National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 2007;25(15):1960–1966.CrossRefPubMedGoogle Scholar
  3. 3.
    Bernhard J, Dietrich D, Scheithauer W, et al.: Clinical benefit and quality of life in patients with advanced pancreatic cancer receiving gemcitabine plus capecitabine versus gemcitabine alone: a randomized multicenter phase III clinical trial – SAKK 44/00-CECOG/PAN.1.3.001. J Clin Oncol 2008;26(22):3695–3701.CrossRefPubMedGoogle Scholar
  4. 4.
    Bernhard J, Dietrich D, Scheithauer W, et al.: Clinical benefit and quality of life in patients with advanced pancreatic cancer receiving gemcitabine plus capecitabine versus gemcitabine alone: a randomized multicenter phase III clinical trial – SAKK 44/00-CECOG/PAN.1.3.001. J Clin Oncol 2008;26(22):3695–3701.CrossRefPubMedGoogle Scholar
  5. 5.
    Burris H, Storniolo AM: Assessing clinical benefit in the treatment of pancreas cancer: gemcitabine compared to 5-fluorouracil. Eur J Cancer 1997;33(Suppl. 1):S18–S22.CrossRefPubMedGoogle Scholar
  6. 6.
    Reyes-Gibby CC, Chan W, Abbruzzese JL, et al.: Patterns of self-reported symptoms in pancreatic cancer patients receiving chemoradiation. J Pain Symptom Manage 2007;34(3):244–252.CrossRefPubMedGoogle Scholar
  7. 7.
    Labori KJ, Hjermstad MJ, Wester T, Buanes T, Loge JH: Symptom profiles and palliative care in advanced pancreatic cancer: a prospective study. Support Care Cancer 2006;14(11):1126–1133.CrossRefPubMedGoogle Scholar
  8. 8.
    Sepulveda C, Marlin A, Yoshida T, Ullrich A: Palliative Care: the World Health Organization's global perspective. J Pain Symptom Manage 2002;24(2):91–96.CrossRefPubMedGoogle Scholar
  9. 9.
    Fitzsimmons D, Johnson CD, George S, et al.: Development of a disease specific quality of life (QoL) questionnaire module to supplement the EORTC core cancer QoL questionnaire, the QLQ-C30 in patients with pancreatic cancer. EORTC study group on Quality of Life. Eur J Cancer 1999;35(6):939–941.CrossRefPubMedGoogle Scholar
  10. 10.
    Yount S, Cella D, Webster K, et al.: Assessment of patient-reported clinical outcome in pancreatic and other hepatobiliary cancers: the FACT hepatobiliary symptom index. J Pain Symptom Manage 2002;24(1):32–44.CrossRefPubMedGoogle Scholar
  11. 11.
    Weiner JS, Roth J: Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life. J Palliat Med 2006;9(2):451–463.CrossRefPubMedGoogle Scholar
  12. 12.
    Quill TE, Arnold RM, Platt F: “I wish things were different”: expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med 2001;135(7):551–555.PubMedGoogle Scholar
  13. 13.
    Spear SJ, Schmidhofer M: Ambiguity and workarounds as contributors to medical error. Ann Intern Med 2005;142(8):627–630.PubMedGoogle Scholar
  14. 14.
    Janjan N, Delclos M, Ballo M, Crane C: Radiotherapy in treating gastrointestinal symptoms. In E Gastrointestinal Symptoms in Advanced Cancer Patients. Ripamonti, C Bruera (eds.). New York: Oxford University Press, 2002, pp. 341–342.Google Scholar
  15. 15.
    Polati E, Luzzani A, Schweiger V, Finco G, Ischia S: The role of neurolytic celiac plexus block in the treatment of pancreatic cancer pain. Transplant Proc 2008;40(4):1200–1204.CrossRefPubMedGoogle Scholar
  16. 16.
    Wong GY, Schroeder DR, Carns PE, et al.: Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial. JAMA 2004;291(9):1092–1099.CrossRefPubMedGoogle Scholar
  17. 17.
    Baghdadi S, Abbas MH, Albouz F, Ammori BJ: Systematic review of the role of thoracoscopic splanchnicectomy in palliating the pain of patients with chronic pancreatitis. Surg Endosc 2008;22(3):580–588.CrossRefPubMedGoogle Scholar
  18. 18.
    Levy MJ, Topazian MD, Wiersema MJ, et al.: Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block. Am J Gastroenterol 2008;103(1):98–103.PubMedGoogle Scholar
  19. 19.
    Bhatnagar S, Gupta D, Mishra S, Thulkar S, Chauhan H: Bedside ultrasound-guided celiac plexus neurolysis with bilateral paramedian needle entry technique can be an effective pain control technique in advanced upper abdominal cancer pain. J Palliat Med 2008;11(9):1195–1199.CrossRefPubMedGoogle Scholar
  20. 20.
    Buscail L, Faure P, Bournet B, Selves J, Escourrou J: Interventional endoscopic ultrasound in pancreatic diseases. Pancreatology 2006;6(1–2):7–16.CrossRefPubMedGoogle Scholar
  21. 21.
    Puli SR, Reddy JB, Bechtold ML, Antillon MR, Brugge WR: EUS-guided celiac plexus neurolysis for pain due to chronic pancreatitis or pancreatic cancer pain: a meta-analysis and systematic review. Dig Dis Sci 2009.Google Scholar
  22. 22.
    Massie MJ: Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr 2004;(32):57–71.Google Scholar
  23. 23.
    Hirschfeld RM, Keller MB, Panico S, et al.: The national depressive and manic-depressive association consensus statement on the undertreatment of depression. JAMA 1997;277(4):333–340.CrossRefPubMedGoogle Scholar
  24. 24.
    Waslick BD, Kander R, Kakouros A: Depression in childern and adults: an overview. In The Many Faces of Depression in Children and Adolescents: An Overview. D Schafer, D Waslick (eds.). Washington DC: American Pyschiatric Publishing, 2002.Google Scholar
  25. 25.
    Kroenke K: A 75-year-old man with depression. JAMA 2002;287(12):1568–1576.CrossRefPubMedGoogle Scholar
  26. 26.
    Kelly S, Yeo J, Robertson GM, Chapman B, Wells JE, Frizelle FA: Functional assessment of bacterial colonization in patients with ileal pouch-anal anastomosis and Brooke ileostomy. Dis Colon Rectum 2004;47(8):1386–1389.CrossRefPubMedGoogle Scholar
  27. 27.
    Penninx BW, Guralnik JM, Ferrucci L, Simonsick EM, Deeg DJ, Wallace RB: Depressive symptoms and physical decline in community-dwelling older persons. JAMA 1998;279(21):1720–1726.CrossRefPubMedGoogle Scholar
  28. 28.
    Lynn J, De Vries KO, Arkes HR, et al.: Ineffectiveness of the SUPPORT intervention: review of explanations. J Am Geriatr Soc 2000;48(Suppl. 5):S206–S213.PubMedGoogle Scholar
  29. 29.
    Callahan CM, Wolinsky FD, Stump TE, Nienaber NA, Hui SL, Tierney WM: Mortality, symptoms, and functional impairment in late-life depression. J Gen Intern Med 1998;13(11):746–752.CrossRefPubMedGoogle Scholar
  30. 30.
    Ford DE, Mead LA, Chang PP, Cooper-Patrick L, Wang NY, Klag MJ: Depression is a risk factor for coronary artery disease in men: the precursors study. Arch Intern Med 1998;158(13):1422–1426.CrossRefPubMedGoogle Scholar
  31. 31.
    Everson SA, Roberts RE, Goldberg DE, Kaplan GA: Depressive symptoms and increased risk of stroke mortality over a 29-year period. Arch Intern Med 1998;158(10):1133–1138.CrossRefPubMedGoogle Scholar
  32. 32.
    Wagner HP: Cancer in childhood and supportive care. Support Care Cancer 1999;7(5):293–294.CrossRefPubMedGoogle Scholar
  33. 33.
    Callahan CM, Kesterson JG, Tierney WM: Association of symptoms of depression with diagnostic test charges among older adults. Ann Intern Med 1997;126(6):426–432.PubMedGoogle Scholar
  34. 34.
    Holland JC, Korzun AH, Tross S, et al.: Comparative psychological disturbance in patients with pancreatic and gastric cancer. Am J Psychiatry 1986;143(8):982–986.PubMedGoogle Scholar
  35. 35.
    Carney CP, Jones L, Woolson RF, Noyes R, Jr., Doebbeling BN: Relationship between depression and pancreatic cancer in the general population. Psychosom Med 2003;65(5):884–888.CrossRefPubMedGoogle Scholar
  36. 36.
    Brown JH, Paraskevas F: Cancer and depression: cancer presenting with depressive illness: an autoimmune disease? Br J Psychiatry 1982;141:227–232.CrossRefPubMedGoogle Scholar
  37. 37.
    Sheibani-Rad S, Velanovich V: Effects of depression on the survival of pancreatic adenocarcinoma. Pancreas 2006;32(1):58–61.CrossRefPubMedGoogle Scholar
  38. 38.
    Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Washington DC: American Psychiatric Association, 1994.Google Scholar
  39. 39.
    Williams JW, Jr., Noel PH, Cordes JA, Ramirez G, Pignone M: Is this patient clinically depressed? JAMA 2002;287(9):1160–1170.CrossRefPubMedGoogle Scholar
  40. 40.
    Mitchell AJ: Are one or two simple questions sufficient to detect depression in cancer and palliative care? A bayesian meta-analysis. Br J Cancer 2008;98(12):1934–1943.CrossRefPubMedGoogle Scholar
  41. 41.
    Tougas G, Eaker EY, Abell TL, et al.: Assessment of gastric emptying using a low fat meal: establishment of international control values. Am J Gastroenterol 2000;95(6):1456–1462.CrossRefPubMedGoogle Scholar
  42. 42.
    Linke R, Meier M, Muenzing W, Folwaczny C, Schnell O, Tatsch K: Prokinetic therapy: what can be measured by gastric scintigraphy? Nucl Med Commun 2005;26(6):527–533.CrossRefPubMedGoogle Scholar
  43. 43.
    Kuo B, McCallum RW, Koch KL, et al.: Comparison of gastric emptying of a nondigestible capsule to a radio-labelled meal in healthy and gastroparetic subjects. Aliment Pharmacol Ther 2008;27(2):186–196.CrossRefPubMedGoogle Scholar
  44. 44.
    Parkman HP, Hasler WL, Fisher RS: American gastroenterological association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology 2004;127(5):1592–1622.CrossRefPubMedGoogle Scholar
  45. 45.
    Bouras EP: Gastroparesis and electrical stimulation: can we afford the power bill? Neurogastroenterol Motil 2005;17(1):2–3.CrossRefPubMedGoogle Scholar
  46. 46.
    Shivshanker K, Bennett RW, Jr., Haynie TP: Tumor-associated gastroparesis: correction with metoclopramide. Am J Surg 1983;145(2):221–225.CrossRefPubMedGoogle Scholar
  47. 47.
    Nelson KA, Walsh TD: Metoclopramide in anorexia caused by cancer-associated dyspepsia syndrome (CADS). J Palliat Care 1993;9(2):14–18.PubMedGoogle Scholar
  48. 48.
    Sturm A, Holtmann G, Goebell H, Gerken G: Prokinetics in patients with gastroparesis: a systematic analysis. Digestion 1999;60(5):422–427.CrossRefPubMedGoogle Scholar
  49. 49.
    Ray WA, Murray KT, Meredith S, Narasimhulu SS, Hall K, Stein CM: Oral erythromycin and the risk of sudden death from cardiac causes. N Engl J Med 2004;351(11):1089–1096.CrossRefPubMedGoogle Scholar
  50. 50.
    Gupta P, Rao SS: Attenuation of isolated pyloric pressure waves in gastroparesis in response to botulinum toxin injection: a case report. Gastrointest Endosc 2002;56(5):770–772.CrossRefPubMedGoogle Scholar
  51. 51.
    Kim CH, Nelson DK: Venting percutaneous gastrostomy in the treatment of refractory idiopathic gastroparesis. Gastrointest Endosc 1998;47(1):67–70.CrossRefPubMedGoogle Scholar
  52. 52.
    Jones MP, Maganti K: A systematic review of surgical therapy for gastroparesis. Am J Gastroenterol 2003;98(10):2122–2129.CrossRefPubMedGoogle Scholar
  53. 53.
    Mukherjee S, Kocher HM,Hutchins RR, Bhattacharya S, Abraham AT: Palliative Surgical Bypass for Pancreatic and Peri-ampullary Cancers. J Gastrointest Cancer 2007;38(2–4):102–107.Google Scholar
  54. 54.
    Lee MG, Lee HJ, Kim MH, et al.: Extrahepatic biliary diseases: 3D MR cholangiopancreatography compared with endoscopic retrograde cholangiopancreatography. Radiology 1997;202(3):663–669.PubMedGoogle Scholar
  55. 55.
    Soderlund C, Linder S: Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial. Gastrointest Endosc 2006;63(7):986–995.CrossRefPubMedGoogle Scholar
  56. 56.
    Park DH, Kim MH, Choi JS, et al.: Covered versus uncovered wallstent for malignant extrahepatic biliary obstruction: a cohort comparative analysis. Clin Gastroenterol Hepatol 2006;4(6):790–796.CrossRefGoogle Scholar
  57. 57.
    DeWys WD, Begg C, Lavin PT, et al.: Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med 1980;69(4):491–497.CrossRefPubMedGoogle Scholar
  58. 58.
    Ottery F: Supportive nutritional management of the patient with pancreatic cancer. Oncology (Williston Park) 1996;10(Suppl. 9):26–32.Google Scholar
  59. 59.
    Falconer JS, Fearon KC, Plester CE, Ross JA, Carter DC: Cytokines, the acute-phase response, and resting energy expenditure in cachectic patients with pancreatic cancer. Ann Surg 1994;219(4):325–331.CrossRefPubMedGoogle Scholar
  60. 60.
    Wakasugi H, Funakoshi A, Iguchi H: Clinical observations of pancreatic diabetes caused by pancreatic carcinoma, and survival period. Int J Clin Oncol 2001;6(1):50–54.CrossRefPubMedGoogle Scholar
  61. 61.
    Esper DH, Harb WA: The cancer cachexia syndrome: a review of metabolic and clinical manifestations. Nutr Clin Pract 2005;20(4):369–376.CrossRefPubMedGoogle Scholar
  62. 62.
    Couch M, Lai V, Cannon T, et al.: Cancer cachexia syndrome in head and neck cancer patients: part I. Diagnosis, impact on quality of life and survival, and treatment. Head Neck 2007;29(4):401–411.CrossRefPubMedGoogle Scholar
  63. 63.
    Camps C, Iranzo V, Bremnes RM, Sirera R: Anorexia-Cachexia syndrome in cancer: implications of the ubiquitin-proteasome pathway. Support Care Cancer 2006;14(12):1173–1183.CrossRefPubMedGoogle Scholar
  64. 64.
    Loprinzi CL, Kugler JW, Sloan JA, et al.: Randomized comparison of megestrol acetate versus dexamethasone versus fluoxymesterone for the treatment of cancer anorexia/cachexia. J Clin Oncol 1999;17(10):3299–3306.PubMedGoogle Scholar
  65. 65.
    Loprinzi CL, Bernath AM, Schaid DJ, et al.: Phase III evaluation of 4 doses of megestrol acetate as therapy for patients with cancer anorexia and/or cachexia. Oncology 1994;51(Suppl. 1):2–7.CrossRefPubMedGoogle Scholar
  66. 66.
    Bossola M, Pacelli F, Tortorelli A, Doglietto GB: Cancer cachexia: it's time for more clinical trials. Ann Surg Oncol 2007;14(2):276–285.CrossRefPubMedGoogle Scholar
  67. 67.
    Jatoi A, Windschitl HE, Loprinzi CL, et al.: Dronabinol versus megestrol acetate versus combination therapy for cancer-associated anorexia: a North Central Cancer Treatment Group study. J Clin Oncol 2002;20(2):567–573.CrossRefPubMedGoogle Scholar
  68. 68.
    Gordon JN, Trebble TM, Ellis RD, Duncan HD, Johns T, Goggin PM: Thalidomide in the treatment of cancer cachexia: a randomised placebo controlled trial. Gut 2005;54(4):540–545.CrossRefPubMedGoogle Scholar
  69. 69.
    Chlebowski RT, Herrold J, Ali I, et al.: Influence of nandrolone decanoate on weight loss in advanced non-small cell lung cancer. Cancer 1986;58(1):183–186.CrossRefPubMedGoogle Scholar
  70. 70.
    Brescia FJ: Palliative care in pancreatic cancer. Cancer Control 2004;11(1):39–45.PubMedGoogle Scholar
  71. 71.
    Lundholm K, Korner U, Gunnebo L, et al.: Insulin treatment in cancer cachexia: effects on survival, metabolism, and physical functioning. Clin Cancer Res 2007;13(9):2699–2706.CrossRefPubMedGoogle Scholar
  72. 72.
    Peter JV, Moran JL, Phillips-Hughes J: A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med 2005;33(1):213–220.CrossRefPubMedGoogle Scholar
  73. 73.
    Stewart GD, Skipworth RJ, Fearon KC: Cancer cachexia and fatigue. Clin Med 2006;6(2):140–143.PubMedGoogle Scholar
  74. 74.
    Bauer J, Capra S, Battistutta D, Davidson W, Ash S: Compliance with nutrition prescription improves outcomes in patients with unresectable pancreatic cancer. Clin Nutr 2005;24(6):998–1004.CrossRefPubMedGoogle Scholar
  75. 75.
    el Kamar FG, Grossbard ML, Kozuch PS: Metastatic pancreatic cancer: emerging strategies in chemotherapy and palliative care. Oncologist 2003; 8(1):18–34.CrossRefPubMedGoogle Scholar
  76. 76.
    Perez MM, Newcomer AD, Moertel CG, Go VL, Dimagno EP: Assessment of weight loss, food intake, fat metabolism, malabsorption, and treatment of pancreatic insufficiency in pancreatic cancer. Cancer 1983;52(2):346–352.CrossRefPubMedGoogle Scholar
  77. 77.
    Bruno MJ, Haverkort EB, Tijssen GP, Tytgat GN, van Leeuwen DJ: Placebo controlled trial of enteric coated pancreatin microsphere treatment in patients with unresectable cancer of the pancreatic head region. Gut 1998;42(1):92–96.CrossRefPubMedGoogle Scholar
  78. 78.
    Ferrone M, Raimondo M, Scolapio JS: Pancreatic enzyme pharmacotherapy. Pharmacotherapy 2007;27(6):910–920.CrossRefPubMedGoogle Scholar
  79. 79.
    Larkin PJ, Sykes NP, Centeno C, et al.: The management of constipation in palliative care: clinical practice recommendations. Palliat Med 2008;22(7):796–807.CrossRefPubMedGoogle Scholar
  80. 80.
    Sykes NP: The pathogenesis of constipation. J Support Oncol 2006;4(5):213–218.PubMedGoogle Scholar
  81. 81.
    Mumford S: Nutrition. 4. High fibre diets. Nurs Mirror 1985;160(10):36–38.PubMedGoogle Scholar
  82. 82.
    Radbruch L, Sabatowski R, Loick G, et al.: Constipation and the use of laxatives: a comparison between transdermal fentanyl and oral morphine. Palliat Med 2000;14(2):111–119.CrossRefPubMedGoogle Scholar
  83. 83.
    Daeninck PJ, Bruera E: Reduction in constipation and laxative requirements following opioid rotation to methadone: a report of four cases. J Pain Symptom Manage 1999;18(4):303–309.CrossRefPubMedGoogle Scholar
  84. 84.
    Thomas J, Karver S, Cooney GA, et al.: Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med 2008;358(22):2332–2343.CrossRefPubMedGoogle Scholar
  85. 85.
    Portenoy RK, Thomas J, Moehl Boatwright ML, et al.: Subcutaneous methylnaltrexone for the treatment of opioid-induced constipation in patients with advanced illness: a double-blind, randomized, parallel group, dose-ranging study. J Pain Symptom Manage 2008;35(5):458–468.CrossRefPubMedGoogle Scholar
  86. 86.
    Herzog TJ, Coleman RL, Guerrieri JP, Jr., et al.: A double-blind, randomized, placebo-controlled phase III study of the safety of alvimopan in patients who undergo simple total abdominal hysterectomy. Am J Obstet Gynecol 2006;195(2):445–453.CrossRefPubMedGoogle Scholar
  87. 87.
    Webster L, Jansen JP, Peppin J, et al.: Alvimopan, a peripherally acting mu-opioid receptor (PAM-OR) antagonist for the treatment of opioid-induced bowel dysfunction: results from a randomized, double-blind, placebo-controlled, dose-finding study in subjects taking opioids for chronic non-cancer pain. Pain 2008;137(2):428–440.CrossRefPubMedGoogle Scholar
  88. 88.
    Smith EM, Jayson GC: The current and future management of malignant ascites. Clin Oncol (R Coll Radiol) 2003;15(2):59–72.Google Scholar
  89. 89.
    Parsons SL, Lang MW, Steele RJ: Malignant ascites: a 2-year review from a teaching hospital. Eur J Surg Oncol 1996;22(3):237–239.PubMedGoogle Scholar
  90. 90.
    Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG: The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992;117(3):215–220.PubMedGoogle Scholar
  91. 91.
    Lee CW, Bociek G, Faught W: A survey of practice in management of malignant ascites. J Pain Symptom Manage 1998;16(2):96–101.CrossRefPubMedGoogle Scholar
  92. 92.
    Pockros PJ, Esrason KT, Nguyen C, Duque J, Woods S: Mobilization of malignant ascites with diuretics is dependent on ascitic fluid characteristics. Gastroenterology 1992;103(4):1302–1306.PubMedGoogle Scholar
  93. 93.
    McNamara P: Paracentesis – an effective method of symptom control in the palliative care setting? Palliat Med 2000;14(1):62–64.CrossRefPubMedGoogle Scholar
  94. 94.
    Rosenberg S, Courtney A, Nemcek AA, Jr., Omary RA: Comparison of percutaneous management techniques for recurrent malignant ascites. J Vasc Interv Radiol 2004;15(10):1129–1131.PubMedGoogle Scholar
  95. 95.
    Adam RA, Adam YG: Malignant ascites: past, present, and future. J Am Coll Surg 2004;198(6):999–1011.CrossRefPubMedGoogle Scholar
  96. 96.
    Parsons SL, Lang MW, Steele RJ: Malignant ascites: a 2-year review from a teaching hospital. Eur J Surg Oncol 1996;22(3):237–239.PubMedGoogle Scholar
  97. 97.
    Kakkar AK, Lemoine NR, Scully MF, Tebbutt S, Williamson RC: Tissue factor expression correlates with histological grade in human pancreatic cancer. Br J Surg 1995;82(8):1101–1104.CrossRefPubMedGoogle Scholar
  98. 98.
    Khorana AA, Fine RL: Pancreatic cancer and thromboembolic disease. Lancet Oncol 2004;5(11):655–663.CrossRefPubMedGoogle Scholar
  99. 99.
    Moore MJ, Goldstein D, Hamm J, et al.: Erlotinib plus gemcitabine compared with gemcitabine alone in patients with advanced pancreatic cancer: a phase III trial of the National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 2007;25(15):1960–1966.CrossRefPubMedGoogle Scholar
  100. 100.
    Lee AY, Levine MN, Baker RI, et al.: Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003;349(2):146–153.CrossRefPubMedGoogle Scholar
  101. 101.
    Khorana AA: The NCCN clinical practice guidelines on venous thromboembolic disease: strategies for improving VTE prophylaxis in hospitalized cancer patients. Oncologist 2007;12(11):1361–1370.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Milind Javle
    • 1
  • Michael Fisch
    • 2
  1. 1.Gastrointestinal Medical OncologyThe University of Texas, MD Anderson Cancer CenterHoustonUSA
  2. 2.General Oncology and Associate ProfessorThe University of Texas, MD Anderson Cancer CenterHoustonUSA

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