The place of radiation therapy (RT) combined to chemotherapy (chemoradiation, CRT) in adjuvant settings to surgery for the management of R-PDAC or BR-PDAC is still not settled due to conflicting results of clinical trials. Nab-paclitaxel is a novel albumin-bound, solvent-free and water-soluble formulation of paclitaxel, an anti-mitotic agent acting on the tubulins. In PDAC, gemcitabine, associated with other chemotherapeutic agents, mostly 5-FU, capecitabine (an orally 5-FU prodrug) or nanoparticle-bound paclitaxel (nab-paclitaxel), is aimed to increase the response rate and survival benefits in patients. This drug is also used as chemotherapeutic agent in many cancers such as breast, ovarian and non-small cell lung cancers, especially paired with platinum-based drugs. On the other hand, gemcitabine exerts its anticancer properties by inhibiting DNA synthesis and thus blocking cell cycle progression. This combination, initially developed to treat metastatic colorectal cancer, was chosen in PDAC treatment for its synergism, differential mechanisms of action and non-overlapping toxicities of the drugs included in the combination. On the one hand, FOLFIRINOX consists of: (1) 5-fluorouracil (5-FU), an antimetabolite drug inhibiting DNA synthesis and folinic acid (leuvocorin) to potentiate the 5-FU anticancer activity (2) irinotecan, a topoisomerase inhibitor inducing DNA strand breaks (3) oxaliplatin, a platinum-based alkylating agent, which inhibits DNA repair and/or DNA synthesis. Other parameters than anatomical consideration, such as tumour biology or patient condition, might be taken into account for this classification and to determine the best treatment option.Īs of now, the main chemotherapeutic agents involved in the management of PDAC are FOLFIRINOX and gemcitabine-based drugs. Unmetastasised PDAC are thus said to be: (1) resectable (R-PDAC), no tumour contact with the mentioned vessels (2) borderline resectable (BR-PDAC) in case of venous involvement, which can be reconstructed after resection (3) locally advanced (LA-PDAC) if there is an extended involvement of the vessels or if the reconstruction is not possible after the resection. At the time of diagnosis, only 15% to 20% of pancreatic cancers are said to be operable, as the tumour is usually in the border of, or even encloses, important vessels such as the celiac artery, portal vein, hepatic artery or superior mesenteric vein/artery. However, the majority of patients are diagnosed at advanced stages since the disease often presents itself with non-specific symptoms such as diffuse abdominal discomfort and loss of appetite. For early stages of unmetastasised PDAC, surgery is the only treatment with curative intention. Median survival rates are going from 25 months for the earliest stage, between 10 to 15 months for locally advanced to less than 5 months for metastatic cancer. Pancreatic ductal adenocarcinoma (PDAC) is the most frequent type of pancreatic cancer (>85%) associated with the highest mortality rate the five-year survival does not exceed 7%. If outcomes are not improved, the disease is predicted to be the second leading cause of cancer mortality within the next decade. As such, when hepatic encephalopathy is documented both of the above codes are assigned.Due to late diagnosis and resistance to treatment, pancreatic cancer represents the fourth cause of cancer related deaths worldwide. This advice is now retired however the advice has been incorporated into the index. In classifying a condition with an underlying cause, if the Alphabetic Index or Excludes note… results in a code for one of the clinical concepts not being assigned, follow the guidelines in ACS 0001 Principal diagnosis/Problems and underlying conditions and assign codes for both the condition and the underlying cause. Previously national coding advice was released for hepatic encephalopathy (Q3058) which stated: In the last six months we have seen the diagnosis of hypovolemic hyponatraemia being increasingly documented in the medical record.
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