Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer death in the UnitedStates with a median survival of <6 mo and a dismal 5-yr survival rate of 3%-5%. The cancer's lethal nature stems from its propensity to rapidly disseminate to the lymphatic system and distant organs. This aggressive biology and resistance to conventional and targeted therapeutic agents leads to a typical clinical presentation of incurable disease at the time of diagnosis. The well-defined serial histopathologic picture and accompanying molecular profiles of PDAC and its precursor lesions have provided the framework for emerging basic and translational research. Recent advances include insights into the cancer's cellular origins, high-resolution genomic profiles pointing to potential new therapeutic targets, and refined mouse models reflecting both the genetics and histopathologic evolution of human PDAC. This confluence of developments offers the opportunity for accelerated discovery and the future promise of improved treatment.
Pancreas anatomy and physiologyThe pancreas, an organ of endodermal derivation, is the key regulator of protein and carbohydrate digestion and glucose homeostasis (Fig. 1). The exocrine pancreas (80% of the tissue mass of the organ) is composed of a branching network of acinar and duct cells that produce and deliver digestive zymogens into the gastrointestinal tract. The acinar cells, which are organized in functional units along the duct network, synthesize and secrete zymogens into the ductal lumen in response to cues from the stomach and duodenum. Within the acinar units near the ducts are centroacinar cells. The endocrine pancreas, which regulates metabolism and glucose homeostasis through the secretion of hormones into the bloodstream, is composed of four specialized endocrine cell types gathered together into clusters called Islets of Langerhans.Mirroring the physiologic and cellular diversity of the pancreas is a spectrum of distinct pancreatic malignancies that possess histological and molecular features that recall the characteristics of the various normal cellular constituents. These multiple tumor types and hallmark features are summarized in Table 1. Pancreatic ductal adenocarcinoma (PDAC), whose nomenclature derives from its histological resemblance to ductal cells, is the most common pancreatic neoplasm and accounts for >85% of pancreatic tumor cases (Warshaw and Fernandez-del Castillo 1992;. PDAC is the focus of this review, and the reader is directed to the following excellent review covering other pancreas cancer types (Hruban et al. 2006b).
Epidemiology of PDACPDAC is associated with only a few known demographic and environmental risk factors and a handful of autosomal dominant genetic conditions. Multiple studies have established advanced age, smoking, and long-standing chronic pancreatitis as clear risk factors; diabetes and obesity also appear to confer increased risk (Everhart and Wright 1995;Fuchs et al. 1996;Gapstur et al. 2000;Michaud et al. 2001;Berrington de Gonzal...