Book Review

Pancreatic Cancer: Pathogenesis, diagnosis, and treatment

N Engl J Med 1999; 340:158-159January 14, 1999

Article

Pancreatic Cancer: Pathogenesis, diagnosis, and treatment
Edited by Howard A. Reber. 347 pp. Totowa, N.J., Humana Press, 1998. $125. ISBN: 0-89603-466-6

Pancreatic cancer has remained an enigma in an age in which great strides have been made in the management of many forms of cancer. The overall morbidity and mortality associated with pancreatic cancer are nearly the same as those presented in textbooks 25 years ago. The only substantial improvement has been the decrease in treatment-related morbidity and mortality. Our overall knowledge of the natural history of pancreatic carcinoma has also changed very little. Pancreatic cancer remains highly prevalent in western society and continues to be an intriguing and challenging problem that clinicians face on a regular basis.

Reber and associates have brought together a fascinating body of information regarding pancreatic cancer. It is as up to date as any information currently available. Part 1 of the book deals with the molecular biology and genetics of pancreatic carcinoma. The authors also explain in great detail what is known about the histopathological features of this disease. The discussion of the precancerous changes that may be found on histologic examination of the pancreatic ducts before the development of carcinoma is very interesting, as is the discussion of a diverse group of related genetic abnormalities that have recently been evaluated. From the point of view of genetics, the evolution of a pancreatic cancer appears to be a very complex process. Unfortunately, this section of the book is not restricted to a review of the specific molecular biologic issues pertaining to pancreatic cancer; rather, it contains a review of a large body of general information about molecular genetics and does not seem particularly germane to the subject at hand. For readers not directly involved in this field, this material will probably seem excessive. The initial portion of the book also reviews many of the growth factors and growth-factor receptors that have been examined in experimental models of neoplasia. This information will be highly relevant for readers who are keenly interested in pancreatic carcinoma, but again, some of the details, particularly those related to the evolution of growth factors and the role of growth factors in other cancers, stray from the topic of the book. This material would perhaps be more appropriately presented in a book dealing with general molecular oncology.

Part 2 of the book carefully discusses the diagnosis and staging of pancreatic carcinoma and the radiologic evaluation of patients who are thought to have the disease. The detailed discussion of tumor antigens will interest those who deal with laboratory diagnosis involving tumor antigens. The book extensively discusses the lack of diagnostic value in many tumor markers currently under study. This discussion is valuable but tedious reading. One particularly interesting section explains the possible use of microsatellite instabilities in the diagnostic process. This fascinating concept may help clinicians understand early tumor formation and aid in screening patients for pancreatic cancer.

Conventional radiologic evaluation of patients who may have pancreatic cancer has changed only slightly over the years. The authors have reviewed the available data concisely. There is an especially good section on the use of computed tomographic scanning, magnetic resonance imaging, and in particular the value of spiral computed tomographic scanning. The repetitive, negative comments about the value of ultrasonography in an obese American population are not very helpful. Nevertheless, this section is an excellent review of the uses of imaging technology in the diagnosis of carcinoma of the pancreas.

Part 3 of the book assesses data concerning all aspects of the treatment of this disease, from standard surgical procedures to wide-field surgical resection and reconstruction as practiced in the United States and Japan. This section provides a large amount of evidence that such extended surgical procedures are of little or no value. This is really not new information and becomes repetitive.

The chapters related to palliative treatment are quite good. The information is current. Procedures discussed include the use of endoscopic stents, both plastic stents and those with metallic walls. There is useful statistical information in this section of the book, and I found it well worth the effort to read. Laparoscopic technology is mentioned, and some potential for its use in the management of this disease is indicated; however, actual data in this section are limited. This lack of completeness is to be expected with such new interventional techniques.

The final sections, regarding the combination of radiation and chemotherapy, indicate the current futility of these therapies in the treatment of pancreatic cancer.

Overall, this is a very nicely constructed book with the most current information available about pancreatic cancer. The sections discussing diagnosis, particularly molecular diagnosis, are well done. The sections on the operative treatments are considered in great detail and will be of great interest to those who regularly carry out operative treatment with curative intent for patients with pancreatic carcinoma. However, the book could have been considerably shorter and provided the same value to readers.

T. Jeffery Wieman, M.D.
University of Louisville, Louisville, KY 40202