Pancreatic Cancer

Aziz Ahmad, MDSurgical Oncology

Mills-Peninsula HospitalApril 23, 2011

Statistics

• 10th most common cancer – 4th leading cause of cancer death

Statistics

• 80% of cases are adenocarcinomas from exocrine pancreas– Less common exocrine tumors include:• IPMN• Mucinous cystadenocarcimomas

• Islet cell tumors• Insulin, glucagon, VIP, sandostatin, gastrin, nonsecreting

• Most common in black males• Median age of diagnosis is 70

Statistics

• Risk Factors:– Smoking– Low Vegtables & Fruits– High red meat– High sugar sweetened drinks– Chronic pancreatitis (especially hereditary)– Diabetes– Obesity– Genetic (5-10%)

• Family history, Puetz-Jerghers, HNPCC, FAP, Ataxia-Telangiectasia, Hereditary Pancreatitis, FAMMM-PC

Presentation

• Nonspecific symptoms– Tumors of body and tail

(25%)• Pain and weight loss

– Tumors of the Head (75%)• Jaundice, steatohrrea, weight

loss, Couvoirsier’s sign, pain

• Labs– Increased LFTs, elevated

CA19-9

Imaging• Ultrasound

– Bile duct distension– Mass

• CT scan with IV contrast– Quality of imaging continues to

improve– Triple phase CT (pancreas protocol)

90% accurate at finding lesions• Endoscopic ultrasound

– Help find lesions not seen on CT– Help determine resectability– Excellent way to get biopsy

• ERCP– Therapeutic as well as diagnostic

Treatment• Needs to be multimodal– Primary care, radiology,

gastroenterology, surgery, & oncology

• Surgery is the only cure– Cure only in those with

complete resections• Otherwise outcome is

poor with surgery

Treatment

• Finding lesions early (hardest job)– High index of suspicion by primary care

• Modern CT technology • Gastroenterologist with specialized skill in ERCP

and EUS• Surgeons with experience in pancreatic surgery• Radiation/medical oncology up to date with

standard of care and knowledge of any promising clinical trials

What is resectable?

• Tumors localized to pancreas – 15-20% of patients

• Locally advanced disease in patients with vascular involvement of less than 50% of portal vein

• Or lymph node spread that is limited – 10-15%– Resection contraindicated in patients:

• >50% involvement of portal vein• Invasion or encasement of SMA (or hepatic artery)

Non Surgical Candidates

• Palliative chemoradiation• Clinical trials– Median survival is about 8 months

• Palliative endoscopic or surgical procedures• 5-10% locally advanced patients not initially

surgical candidates can be downstaged

General Survival Data

• Overall prognosis seems dismal• 70-80% of patients present as inoperable due

to metastatic disease or locally advanced disease– Median survival only 4-6 months

• 20-30% are operable with localized or resectable locally advanced disease

• Successful operation can give five year survivals from 20-30%

Surgical Procedures

• Tumors of the Body and Tail– Laparoscopic distal

pancreatectomy• Removal of body &

tail of pancreas• spleen

Surgical Procedures• Head of the

pancreas: Whipple Procedure– Removal of:

• Distal stomach• Duodenum and

proximal jejunem• Head of pancreas• Gallbladder and

common bile duct

Complications

• Whipple Procedure– bleeding– Gastroparesis– Pancreatic duct leak– Bile duct leak– Diabetes– malabsorption

• Distal pancreatectomy– Bleeding– Pancreatic duct leak– Malabsorption– diabetes

Complications

• Particularly Whipple procedure thought to have poor surgical outcomes

• Mills-Peninsula experience in the last 40 Whipples:– 5% 60 day mortality

• Even in patients that recur after 2-3 years, quality of life is excellent before symptoms of disease return

Adjuvant Treatment

• Most patients go on to get adjuvant treatment– Gemcitibine based

chemotherapy– Radiation to the surgical

bed• Even with this 70-80% of

patients recur

Why Does it Recur?

• Pancreas with rich vascular and lymphatic supply– Early lymph node spread• Microscopic at the time of surgery

• Currently best chemo with only 25-30% response rate

Conclusion

• So at this time the best answer is to catch the disease early

• In those that you can detect disease early, all hope is not lost

• With an operation, you not only give a chance for cure, but you give hope