Současné trendy v diagnostice karcinomu pankreatu
Authors:
Petr Vanek 1,2; Michal Eid 3; Robert Psar 2,4,5; Vincent Zoundjiekpon 1,2; Ondrej Urban 1,2; Lumír Kunovský 1,2,6,7
Authors‘ workplace:
Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
2; Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
3; Department of Radiology, University Hospital Olomouc, Olomouc, Czech Republic
4; Department of Radiology, Vitkovice Hospital, Ostrava, Czech Republic
5; Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
6; Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Brno, Czech Republic
7; nd Department of Internal Medicine – Gastroenterology and Geriatrics, University Hospital Olomouc, Olomouc, Czech Republic
12
Published in:
Vnitř Lék 2022; 68(6): 363-370
Category:
Main Topic
doi:
https://doi.org/10.36290/vnl.2022.076
Overview
Duktální adenokarcinom pankreatu (pancreatic ductal adenocarcinoma – PDAC) je obávanou malignitou s velice nízkým 5letým přežíváním i přes veškeré snahy o zdokonalení léčebných strategií. V současnosti je včasná detekce považována za nejúčinnější způsob, jak zlepšit přežití, jelikož pouze radikální resekce představuje kurativní potenciál. PDAC se dělí do čtyř kategorií podle rozsahu onemocnění: resekabilní, hraničně resekabilní, lokálně pokročilý a metastatický. Většina pacientů je bohužel diagnostikována s lokálně pokročilým nebo metastatickým onemocněním, a tím pádem není způsobilá pro kurativní resekci. To je dáno především absencí průvodních příznaků či jejich nevýrazností v době, kdy ještě onemocnění není lokálně pokročilé. Vhodná indikace a rychlá dostupnost adekvátních diagnostických nástrojů je nicméně rovněž kritickým bodem vzhledem k agresivní povaze onemocnění. Nákladově efektivní biomarker s vysokou specificitou a senzitivitou umožňující včasnou detekci PDAC bez potřeby pokročilých a invazivních metod stále chybí. Diagnostika tak zůstává závislá na radiologických metodách a endoskopické ultrasonografii. V naší přehledové práci shrnujeme nejnovější epidemiologická data, rizikové faktory, klinickou manifestaci a současné diagnostické trendy se zaměřením na sérové biomarkery a zobrazovací modality. Kromě toho popisujeme aktuální terapeutické postupy.
Klíčová slova:
duktální adenokarcinom pankreatu – pankreas – karcinom pankreatu – diagnostika karcinomu pankreatu – management karcinomu pankreatu – léčba karcinomu pankreatu
Sources
1. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 2021; 71(3):209-249. doi: 10.3322/caac.21660.
2. Arnold M, Abnet CC, Neale RE, et al. Global Burden of 5 Major Types of Gastrointestinal Cancer. Gastroenterology 2020; 159(1):335-349.e15. doi: 10.1053/j.gastro.2020.02.068.
3. Dusek L, Muzik J, Kubasek M, et al. Epidemiology of Malignant Tumours in the Czech Republic. [online]. 2022. [cit. 2022-2-26]. Available at: http://www.svod.cz.
4. Ústav zdravotnických informací a statistiky České republiky. Novotvary 2018 ČR. [online]. 2022. [cit. 2022-02-26]. Available at: https://www.uzis.cz/res/f/008352/novotvary2018.pdf.
5. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin 2020; 70(1):7-30. doi: 10.3322/caac.21590.
6. Rahib L, Smith BD, Aizenberg R, et al. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res 2014; 74(11):2913-21. doi: 10.1158/0008-5472.CAN-14-0155.
7. Huang L, Jansen L, Balavarca Y, et al. Resection of pancreatic cancer in Europe and USA: an international large-scale study highlighting large variations. Gut 2019; 68:130–9. doi:10.1136/ gutjnl-2017-314828.
8. National Cancer Institute. Cancer Stat Facts: Pancreatic Cancer. [online]. 2021. [cit. 2021-08- 29]. Available at: https://seer.cancer.gov/statfacts/html/pancreas.html.
9. Hernandez YG, Lucas AL. MicroRNA in pancreatic ductal adenocarcinoma and its precursor lesions. World J Gastrointest Oncol 2016; 8(1): 18-29. doi: http://dx.doi.org/10.4251/ wjgo.v8.i1.18
10. Falasca M, Kim M, Casari I. Pancreatic cancer: Current research and future directions. Biochim Biophys Acta 2016; 1865(2):123-32. doi: 10.1016/j.bbcan.2016.01.001.
11. Gharibi A, Adamian Y, Kelber JA. Cellular and molecular aspects of pancreatic cancer. Acta Histochem 2016; 118(3):305-16. doi: 10.1016/j.acthis.2016.01.009.
12. Zhang X, Shi S, Zhang B, et al. Circulating biomarkers for early diagnosis of pancreatic cancer: facts and hopes. Am J Cancer Res 2018; 8(3):332-353.
13. Ryska M. Karcinom pankreatu – současný efektivní diagnostický a terapeutický postup. Cas Lek Ces 2016; 155:38–43.
14. Aslanian HR, Lee JH, Canto MI. AGA Clinical Practice Update on Pancreas Cancer Screening in High-Risk Individuals: Expert Review. Gastroenterology 2020; 159(1):358-362. doi: 10.1053/j.gastro.2020.03.088.
15. Owens DK, Davidson KW, Krist AH, et al. Screening for pancreatic cancer: US preventive services Task force reaffirmation recommendation statement. JAMA 2019; 322:438–44. doi:10.1001/jama.2019.10232.
16. Goggins M, Overbeek KA, Brand R, et al. Management of patients with increased risk for familial pancreatic cancer: updated recommendations from the International Cancer of the Pancreas Screening (CAPS) Consortium. Gut 2020; 69(1):7-17. doi: 10.1136/gutjnl-2019-319352.
17. Bosetti C, Lucenteforte E, Silverman DT, et al. Cigarette smoking and pancreatic cancer: an analysis from the International Pancreatic Cancer Case-Control Consortium (Panc4). Ann Oncol 2012; 23(7):1880-8. doi: 10.1093/annonc/mdr541.
18. Iodice S, Gandini S, Maisonneuve P, Lowenfels AB. Tobacco and the risk of pancreatic cancer: a review and meta-analysis. Langenbecks Arch Surg 2008; 393(4):535-45. doi: 10.1007/ s00423-007-0266-2.
19. Mizrahi JD, Surana R, Valle JW, Shroff RT. Pancreatic cancer. Lancet 2020; 395(10242):2008- 2020. doi: 10.1016/S0140-6736(20)30974-0.
20. Stolzenberg-Solomon RZ, Schairer C, Moore S, et al. Lifetime adiposity and risk of pancreatic cancer in the NIH-AARP Diet and Health Study cohort. Am J Clin Nutr 2013; 98(4):1057-65. doi: 10.3945/ajcn.113.058123.
21. Everhart J, Wright D. Diabetes mellitus as a risk factor for pancreatic cancer. A meta-analysis. JAMA 1995;273(20):1605-9.
22. Andersen DK, Korc M, Petersen GM, Eibl G, et al. Diabetes, Pancreatogenic Diabetes, and Pancreatic Cancer. Diabetes 2017; 66(5):1103-1110. doi: 10.2337/db16-1477.
23. Sung H, Siegel RL, Rosenberg PS, Jemal A. Emerging cancer trends among young adults in the USA: analysis of a population-based cancer registry. Lancet Public Health 2019; 4(3):e137-e147. doi: 10.1016/S2468-2667(18)30267-6.
24. Rebours V, Gaujoux S, d‘Assignies G, et al. Obesity and Fatty Pancreatic Infiltration Are Risk Factors for Pancreatic Precancerous Lesions (PanIN). Clin Cancer Res 2015; 21(15):3522-8. doi: 10.1158/1078-0432.CCR-14-2385.
25. Klein AP, Brune KA, Petersen GM, et al. Prospective risk of pancreatic cancer in familial pancreatic cancer kindreds. Cancer Res 2004; 64(7):2634-8. doi: 10.1158/0008-5472.can-03-3823.
26. Schneider R, Slater EP, Sina M, et al. German national case collection for familial pancreatic cancer (FaPaCa): ten years experience. Fam Cancer 2011; 10(2):323-30. doi: 10.1007/ s10689-010-9414-x.
27. Vanek P, Slodicka P, Zoundjiekpon V. Pancreatic cancer screening: ready for prime time?. Gastroent Hepatol 2021; 75(5):390-398. doi: 10.48095/ccgh2021390.
28. Park W, Chawla A, O‘Reilly EM. Pancreatic Cancer: A Review. JAMA 2021; 326(9):851-862. doi: 10.1001/jama.2021.13027.
29. McGuigan A, Kelly P, Turkington RC, et al. Pancreatic cancer: a review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol 2018; 24(43):4846–4861. doi:10.3748/wjg.v24.i43.4846
30. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer Statistics, 2021. CA Cancer J Clin 2021; 71(1):7- 33. doi: 10.3322/caac.21654.
31. Macdonald S, Macleod U, Campbell NC, et al. Systematic review of factors influencing patient and practitioner delay in diagnosis of upper gastrointestinal cancer. Br J Cancer 2006; 94(9):1272-80. doi: 10.1038/sj.bjc.6603089.
32. Walter FM, Mills K, Mendonça SC, et al. Symptoms and patient factors associated with diagnostic intervals for pancreatic cancer (SYMPTOM pancreatic study): a prospective cohort study. Lancet Gastroenterol Hepatol 2016; 1(4):298-306. doi: 10.1016/S2468-1253(16)30079-6.
33. Schmidt-Hansen M, Berendse S, Hamilton W. Symptoms of Pancreatic Cancer in Primary Care: A Systematic Review. Pancreas 2016; 45(6):814-8. doi: 10.1097/MPA.0000000000000527.
34. Kunovsky L, Dite P, Jabandziev P, et al. Causes of Exocrine Pancreatic Insufficiency Other Than Chronic Pancreatitis. J Clin Med 2021; 10(24):5779. doi: 10.3390/jcm10245779.
35. Sharma A, Smyrk TC, Levy MJ, et al. Fasting blood glucose levels provide estimate of duration and progression of pancreatic cancer before diagnosis. Gastroenterology 2018; 155(2): 490–500. doi: 10.1053/j.gastro.2018.04.025.
36. Sah RP, Sharma A, Nagpal S, et al. Phases of metabolic and soft tissue changes in months preceding a diagnosis of pancreatic ductal adenocarcinoma. Gastroenterology 2019; 156(6): 1742–1752. doi: 10.1053/j.gastro.2019.01.039.
37. Ducreux M, Cuhna AS, Caramella C, et al. Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015; 26 Suppl 5:v56-68. doi: 10.1093/annonc/mdv295.
38. Lang J, Kunovsky L, Kala Z, Trna J. Risk factors of pancreatic cancer and their possible uses in diagnostics. Neoplasma 2021; 68(2):227-239. doi: 10.4149/neo_2020_200706N699.
39. Ballehaninna UK, Chamberlain RS. The clinical utility of serum CA 19-9 in the diagnosis, prognosis and management of pancreatic adenocarcinoma: An evidence based appraisal. J Gastrointest Oncol 2012; 3(2):105-19. doi: 10.3978/j.issn.2078-6891.2011.021.
40. Kaur S, Baine MJ, Jain M, et al. Early diagnosis of pancreatic cancer: Challenges and new developments. Biomark Med 2012; 6(5): 597–612. doi:10.2217/bmm.12.69.
41. Locker GY, Hamilton S, Harris J, et al. ASCO 2006 update of recommendations for the use of tumor markers in gastrointestinal cancer. J Clin Oncol 2006; 24(33):5313-27. doi: 10.1200/ JCO.2006.08.2644.
42. Kunovsky L, Tesarikova P, Kala Z, et al. The Use of Biomarkers in Early Diagnostics of Pancreatic Cancer. Can J Gastroenterol Hepatol 2018; 2018:5389820. doi: 10.1155/2018/5389820.
43. Kim JE, Lee KT, Lee JK, et al. Clinical usefulness of carbohydrate antigen 19-9 as a screening test for pancreatic cancer in an asymptomatic population. J Gastroenterol Hepatol 2004; 19(2):182-6. doi: 10.1111/j.1440-1746.2004.03219.x.
44. Eid M, Karousi P, Kunovsky L, et al. The Role of Circulating MicroRNAs in Patients with Early- Stage Pancreatic Adenocarcinoma. Biomedicines 2021; 9(10):1468. doi: 10.3390/biomedicines9101468.
45. Kau SY, Shyr YM, Su CH, et al. Diagnostic and prognostic values of CA 19-9 and CEA in periampullary cancers. J Am Coll Surg 1999; 188(4):415-20. doi: 10.1016/s1072-7515(98)00326-3.
46. Goonetilleke KS, Siriwardena AK. Systematic review of carbohydrate antigen (CA 19-9) as a biochemical marker in the diagnosis of pancreatic cancer. Eur J Surg Oncol 2007; 33(3):266- 70. doi: 10.1016/j.ejso.2006.10.004.
47. Mann DV, Edwards R, Ho S, et al. Elevated tumour marker CA19-9: clinical interpretation and influence of obstructive jaundice. Eur J Surg Oncol 2000; 26(5):474-9. doi: 10.1053/ ejso.1999.0925.
48. Goggins M. Molecular markers of early pancreatic cancer. J Clin Oncol. 2005 Jul 10;23(20):4524-31. doi: 10.1200/JCO.2005.19.711.
49. Fahrmann JF, Schmidt CM, Mao X, et al. Lead-Time Trajectory of CA19-9 as an Anchor Marker for Pancreatic Cancer Early Detection. Gastroenterology 2021; 160(4):1373-1383.e6. doi: 10.1053/j.gastro.2020.11.052.
50. Bauer TM, El-Rayes BF, Li X, et al. Carbohydrate antigen 19-9 is a prognostic and predictive biomarker in patients with advanced pancreatic cancer who receive gemcitabine-containing chemotherapy: a pooled analysis of 6 prospective trials. Cancer 2013; 119(2):285-92. doi: 10.1002/cncr.27734.
51. Tzeng CW, Balachandran A, Ahmad M, et al. Serum carbohydrate antigen 19-9 represents a marker of response to neoadjuvant therapy in patients with borderline resectable pancreatic cancer. HPB (Oxford) 2014; 16(5):430-8. doi: 10.1111/hpb.12154.
52. Wong D, Ko AH, Hwang J, et al. Serum CA19-9 decline compared to radiographic response as a surrogate for clinical outcomes in patients with metastatic pancreatic cancer receiving chemotherapy. Pancreas 2008; 37(3):269-74. doi: 10.1097/MPA.0b013e31816d8185.
53. Pelzer U, Hilbig A, Sinn M, et al. Value of carbohydrate antigen 19-9 in predicting response and therapy control in patients with metastatic pancreatic cancer undergoing first-line therapy. Front Oncol 2013; 3:155. doi: 10.3389/fonc.2013.00155.
54. Hartwig W, Strobel O, Hinz U, et al. CA19-9 in potentially resectable pancreatic cancer: perspective to adjust surgical and perioperative therapy. Ann Surg Oncol 2013; 20(7):2188- 96. doi: 10.1245/s10434-012-2809-1.
55. Kamisawa T, Wood LD, Itoi T, Takaori K. Pancreatic cancer. Lancet 2016; 388(10039):73–85. doi:10.1016/s0140-6736(16)00141-0
56. Zhao Z, Liu W. Pancreatic Cancer: A Review of Risk Factors, Diagnosis, and Treatment. Technol Cancer Res Treat 2020; 19. doi: 10.1177/1533033820962117.
57. Rawat M, Kadian K, Gupta Y, et al. MicroRNA in Pancreatic Cancer: From Biology to Therapeutic Potential. Genes (Basel) 2019; 10(10):752. doi: 10.3390/genes10100752.
58. Johansen JS, Calatayud D, Albieri V, et al. The potential diagnostic value of serum microRNA signature in patients with pancreatic cancer. Int J Cancer 2016; 139(10):2312-24. doi: 10.1002/ijc.30291.
59. Liu J, Gao J, Du Y, et al. Combination of plasma microRNAs with serum CA19-9 for early detection of pancreatic cancer. Int J Cancer 2012; 131(3):683–691. doi:10.1002/ijc.26422
60. Schultz NA, Dehlendorff C, Jensen BV, et al. MicroRNA biomarkers in whole blood for detection of pancreatic cancer. JAMA 2014; 311(4):392–404, doi:10.1001/jama.2013.284664
61. Shams R, Saberi S, Zali M, et al. Identification of potential microRNA panels for pancreatic cancer diagnosis using microarray datasets and bioinformatics methods. Sci Rep 2020; 10(1):7559. doi: 10.1038/s41598-020-64569-1.
62. Iwagami Y, Eguchi H, Nagano H, et al. miR-320c regulates gemcitabine-resistance in pancreatic cancer via SMARCC1. Br J Cancer 2013; 109(2):502-11. doi: 10.1038/bjc.2013.320.
63. Martini V, Timme-Bronsert S, Fichtner-Feigl S, et al. Circulating Tumor Cells in Pancreatic Cancer: Current Perspectives. Cancers 2019; 11(11). doi:10.3390/cancers11111659.
64. Zhang L, Sanagapalli S, Stoita A. Challenges in diagnosis of pancreatic cancer. World J Gastroenterol 2018; 24(19):2047-2060. doi: 10.3748/wjg.v24.i19.2047.
65. Okaniwa S. How Does Ultrasound Manage Pancreatic Diseases? Ultrasound Findings and Scanning Maneuvers. Gut Liver 2020; 14(1):37-46. doi: 10.5009/gnl18567.
66. Kanno A, Masamune A, Hanada K, et al. Multicenter study of early pancreatic cancer in Japan. Pancreatology 2018; 18(1):61-67. doi: 10.1016/j.pan.2017.11.007.
67. Chu LC, Park S, Kawamoto S, et al. Pancreatic Cancer Imaging: A New Look at an Old Problem. Curr Probl Diagn Radiol 2021; 50(4):540-550. doi: 10.1067/j.cpradiol.2020.08.002.
68. Jutric Z, Melstrom LG. New Treatment Options and Management Considerations in Borderline Resectable Pancreatic Cancer. Oncology (Williston Park) 2017; 31(6):443-52.
69. Joo I, Lee JM, Lee ES, et al. Preoperative CT Classification of the Resectability of Pancreatic Cancer: Interobserver Agreement. Radiology 2019; 293(2):343-349. doi: 10.1148/radiol. 2019190422.
70. Hong SB, Lee SS, Kim JH, et al. Pancreatic Cancer CT: Prediction of Resectability according to NCCN Criteria. Radiology 2018; 289(3):710-718. doi: 10.1148/radiol.2018180628.
71. Shen YN, Bai XL, Li GG, Liang TB. Review of radiological classifications of pancreatic cancer with peripancreatic vessel invasion: are new grading criteria required? Cancer Imaging 2017; 17(1):14. doi: 10.1186/s40644-017-0115-7.
72. Pietryga JA, Morgan DE. Imaging preoperatively for pancreatic adenocarcinoma. J Gastrointest Oncol 2015; 6(4):343-57. doi: 10.3978/j.issn.2078-6891.2015.024.
73. Elbanna KY, Jang HJ, Kim TK. Imaging diagnosis and staging of pancreatic ductal adenocarcinoma: a comprehensive review. Insights Imaging 2020; 11(1):58. doi: 10.1186/s13244- 020-00861-y.
74. Blouhos K, Boulas KA, Tsalis K, Hatzigeorgiadis A. The isoattenuating pancreatic adenocarcinoma: Review of the literature and critical analysis. Surg Oncol 2015; 24(4):322-8. doi: 10.1016/j.suronc.2015.09.006.
75. Psar R, Urban O, Cerna M, et al. Improvement of the Diagnosis of Isoattenuating Pancreatic Carcinomas by Defining their Characteristics on Contrast Enhanced Computed Tomography and Endosonography with Fine-Needle Aspiration (EUS-FNA). Diagnostics (Basel) 2021; 11(5):776. doi: 10.3390/diagnostics11050776.
76. Kobashi Y, Uchiyama M, Matsui J. The „K-Sign“-A Novel CT Finding Suggestive before the Appearance of Pancreatic Cancer. Cancers (Basel) 2021; 13(16):4222. doi: 10.3390/cancers13164222.
77. Yamao K, Tsurusaki M, Takashima K, et al. Analysis of Progression Time in Pancreatic Cancer including Carcinoma In Situ Based on Magnetic Resonance Cholangiopancreatography Findings. Diagnostics (Basel) 2021; 11(10):1858. doi: 10.3390/diagnostics11101858.
78. Scheufele F, Schorn S, Demir IE, et al. Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in the pancreatic head: A meta-analysis of current literature. Surgery 2017; 161(4):939-950. doi: 10.1016/j.surg.2016.11.001.
79. DeWitt J, Devereaux B, Chriswell M, et al. Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer. Ann Intern Med 2004; 141(10):753-63. doi: 10.7326/0003-4819-141-10-200411160-00006.
80. Kitano M, Yoshida T, Itonaga M, et al. Impact of endoscopic ultrasonography on diagnosis of pancreatic cancer. J Gastroenterol 2019; 54(1):19-32. doi: 10.1007/s00535-018-1519-2.
81. Săftoiu A, Vilmann P. Role of endoscopic ultrasound in the diagnosis and staging of pancreatic cancer. J Clin Ultrasound 2009; 37(1):1-17. doi: 10.1002/jcu.20534.
82. Klapman JB, Chang KJ, Lee JG, Nguyen P. Negative predictive value of endoscopic ultrasound in a large series of patients with a clinical suspicion of pancreatic cancer. Am J Gastroenterol 2005; 100(12):2658-61. doi: 10.1111/j.1572-0241.2005.00315.x.
83. Puli SR, Singh S, Hagedorn CH, et al. Diagnostic accuracy of EUS for vascular invasion in pancreatic and periampullary cancers: a meta-analysis and systematic review. Gastrointest Endosc 2007; 65(6):788-97. doi: 10.1016/j.gie.2006.08.028.
84. Conroy T, Hammel P, Hebbar M, et al. FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer. N Engl J Med 2018; 379(25):2395-2406. doi: 10.1056/NEJMoa1809775.
85. Versteijne E, Suker M, Groothuis K, et al. Preoperative Chemoradiotherapy Versus Immediate Surgery for Resectable and Borderline Resectable Pancreatic Cancer: Results of the Dutch Randomized Phase III PREOPANC Trial. J Clin Oncol 2020; 38(16):1763-1773. doi: 10.1200/JCO.19.02274.
86. Hackert T, Sachsenmaier M, Hinz U, et al. Locally Advanced Pancreatic Cancer: Neoadjuvant Therapy With Folfirinox Results in Resectability in 60% of the Patients. Ann Surg 2016; 264(3):457-463. doi:10.1097/SLA.0000000000001850.
87. Tempero MA, Malafa MP, Al-Hawary M, et al. Pancreatic Adenocarcinoma, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19(4):439-457. doi:10.6004/jnccn.2021.0017.
88. Gränsmark E, Bågenholm Bylin N, Blomstrand H, et al. Real World Evidence on Second- Line Palliative Chemotherapy in Advanced Pancreatic Cancer. Front Oncol 2020; 10:1176. doi:10.3389/fonc.2020.01176.
89. Golan T, Hammel P, Reni M, et al. Maintenance Olaparib for Germline BRCA-Mutated Metastatic Pancreatic Cancer. N Engl J Med 2019; 381(4):317-327. doi:10.1056/NEJMoa1903387.
90. Leroux C, Konstantinidou G. Targeted Therapies for Pancreatic Cancer: Overview of Current Treatments and New Opportunities for Personalized Oncology. Cancers (Basel) 2021; 13(4):799. doi:10.3390/cancers13040799.
Labels
Diabetology Endocrinology Internal medicineArticle was published in
Internal Medicine
2022 Issue 6
Most read in this issue
- Časný karcinom žaludku
- Současné trendy v diagnostice karcinomu pankreatu
- Komplexní přístup k pacientovi s arteriální hypertenzí a dyslipidemií
- SGLT-2 inhibice užitečným nástrojem v léčbě srdečního selhání se sníženou i zachovalou ejekční frakcí