Pancreatic Cancer

by RAMKUMAR

Pancreas - Anatomy

Overview

• Pancreatic cancer develops when a cell in the pancreas acquires damage to its DNA that causes A single cell to grows and divides rapidly, becoming a tumor that does not respect normal boundaries in the body.

Pancreatic Epithelial Malignancies :

• Malignant– Ductal adenocarcinoma (majority)– Mucinous cystadenocarcinoma– Acinar cell carcinoma– Small cell carcinoma

• Uncertain malignant potential– Mucinous cystadenoma– Solid and cystic papillary neoplams

• Pathology: – mostly ductal adenocarcinoma (metastasizes early; presents late)

Location of tumor:- 60% head- 25% body- 15% tail

Epidemiology:

• 10th most common cancer .• 4th leading cause of cancer death.• 80% of cases are adenocarcinomas from exocrine pancreas– Less common exocrine tumors include:

• IPMN• Mucinouscystadenocarcimomas

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

Causes And Risk Factors:

• Pancreatic cancer is fundamentally a disease caused by damage to the DNA. This damage is often referred to as mutations.(Inheritance or Carcinogens).• Smoking• Age, gender• Obesity• Diet – high fat, low fibre• Chronic pancreatitis• Family history – BRCA2• Β-napthylamine

Sign & Symptoms :

Jaundice Pain in the upper or middle abdomen and back Unexplaind weight loss Loss of appetite Fatigue Trousseau’s syndrome Clinical Depression

Diagnostic Procedures:

• Identifying risk factors.• Mass during physical Examination• Ultrasound

– Bile duct distension– Mass

• CT scan with IV contrast– Triple phase CT (pancreas protocol) 90% accurate at finding

lesions– A scanner takes multiple X-ray pictures, and a

computer reconstructs them into detailed images of the inside of the abdomen

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

• MR cholangiopancreatography (MRCP), which can be used to look at the pancreatic and bile ducts, is described below in the section on cholangiopancreatography.

• MR angiography (MRA), which looks at blood vessels, is mentioned below in the section on angiography.

MRCP

ULTRASOUND CT SCAN

Endoscopic retrograde cholangiopancreatography (ERCP):

• For this test, an endoscope (a thin, flexible tube with a tiny video camera on the end) is passed down the throat, through the esophagus and stomach, and into the first part of the small intestine. This is usually done while you are sedated (given medicine to make you sleepy).

• A small amount of dye (contrast material) is then injected into the common bile duct, and x-rays are taken.

• The x-ray images can show narrowing or blockage in these ducts that might be due to pancreatic cancer.

• ERCP can also be used to place a stent (small tube) into a bile or pancreatic duct to keep it open if a nearby tumor is pressing on it.

• Stages of pancreatic cancer:

I II III IV

Stages :

Sites of Metastasis:

• Liver• Peritoneum• Lung• Adrenal• Bone• Rarely CNS

Treatment Approach

Resectable disease

Stages I-II(20%)

SurgeryAdjuvant chemotherapy

Adjuvant radiation

Treatment Approach

Inoperable disease

Locally Advanced stage III

(30-40^)

ChemoradiationChemotherapy

Metatatic Stage IV(40-50%)

ChemotherapySupportive Care

• Surgery: Surgery with the intention of a cure is only

possible in around one-fifth (20%) of new cases.• Whipple`s procedure• total pancreatectomy• distal pancreatectomy

– radiation therapy– chemotherapy

• Whipple`s procedure:

Management of Locally Advanced Pancreatic Cancer:

• Conventional external beam radiation therapy• Concomitant Chemoradiotherapy–5-FU–Gemcitabine–Paclitaxel

Management of Metastatic Pancreatic Cancer:

• Pain Control– Long-acting narcotics– Neurolytic celiac plexus block (NCPB)

• PERT– PPI– Bacterial overgrowth

• Endoscopic Stenting of Biliary and Pancreatic Obstruction

Chemotherapy for Metastatic Pancreatic Cancer

• 5-FU• Gemcitabine– Median survival times versus 5-FU– Survival rate at 12-months– Toxicities– Optimizing efficiencyCombination Chemotherapy Trials

Prognosis:

• 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%

Conclusions

Since 1996, 20 randomized phase III trials have failed to produce improvement in survival outcomes.

Metastatic pancreatic cancer is one of the most frustrating malignancies to treat.

For now, gemcitabine, gemcitabine + erlotinib, and second-line treatment with OFF has shown benefit.

Supportive care strategies should be emphasized.

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