pancreatic carcinoma
TRANSCRIPT
PANCREATIC CARCINOMA PANCREATIC CARCINOMA
“AN OVERVIEW” “AN OVERVIEW”
• 3rd most common GIT cancer.
• 4th most common cause of cancer
death
• Death to incidence ratio is one.
( lowest among all types of cancer).
why???
• Male:Female ratio 2:1
• Peak age 65 to 75 yrs
• Common in black americans
Introduction
Risk factors
1- Cigarette smoking.
2- Increased age.
3- Chronic pancreatitis.
4- Increased saturated fat intake.
5- Exposure to nonchlorinated solvents
Molecular genetics
• Chronic familial relapsing pancreatitis.
• Familial breast cancer ( BRCA2).
• Peutz –Jeghers syndrome.
• HNPCC (Hereditary non polyposis
colorectal cancer)
• Gardener syndrome.
• Familial atypical mole and melanoma
syndrome.
Genetic progression due
to PanIN dysplasia
Pathology
• Site:55% head of pancreas;25% body
15% tail; 5% periampulary
• Macroscopic: growth is
hard&infiltrating
• Histology:90% ductal adeno ca;
9% cystic neoplasms
1% endocrine neoplasms
• Spread:Lymphatics to peritoneum &
regional nodes
Blood to liver & lung
Presenting symptoms
• Head&Periampulary: Painless progressive
jaundice with palpable GB- “Courvoisier’s Law”;
Vomiting due to duodenal block;
Pruritus,dark urine & clay color stool
• Body: back pain,anorexia,weight loss &
steatorrhea
• Tail: often presents with metastases,malignant
ascites or unexplained anemia
Pancreatic Carcinoma
Investigations
• Lab: Elevated total & direct bilirubin
High Alk Phosphatase& GGT
Tumor marker CA19-9 >200U/ml
• USG abd: can detect huge tumors
can’t pickup small mass
• MDCT: with arterial & portal venous
phase is sensitive to pickup
even small hypodense lesions
Pancreatic Carcinoma
Investigations
• ERCP & MRCP: “Dual duct sign”
Therapeutic ERCP for palliative stent in
CBD & Duodenum
• Endoscopic Ultrasound:(EUS)
Excellent for staging the tumor
EUS guided pancreatic biopsy
Pancreatic Carcinoma
CT Abdomen
Pancreatic Carcinoma
ERCP “Dual Duct Sign”
Pancreatic Carcinoma
Periampulary Mass&EUS
Staging
Stage1:Tumor is limited to pancreas with no
nodes or metastases
Stage2:Tumor extends into bile duct,
peripancreatic tissues or duodenum No nodes
or metastases
Stage3:as stage 2 + positive nodes or celiac or
SMA involvement
Staging
Stage4a: Tumor extends to
stomach,colon,spleen or major vessels
with any nodal status and no distant
metastases
Stage4b: Distant metastases with any
nodal status or tumor size
Pancreatic Carcinoma
Management
• Rescectable tumors
• Borderline resectability
• Unresectable tumors
Resectable tumors
• Normal fat planes between tumor and
SMA, SMV
• Absence of extrapancreatic disease
• Patent SMPV confluence
• No direct extension to celiac axis or
SMA
Borderline tumors
• Short segment occlusion of SMPV
confluence with an adequate vessele for
grafting
• Short segment (< 1 cm ) abutment of the
common or proper hepatic artery or
SMA on high quality CT
Absolute Contraindications
• Extrapancreatic disease- distant
metastases
• Encasement of coelic axis or SMA
( anything more than short
abutment)
Pancreatic Carcinoma
Management
Whipple’s Operation
Pancreatoduodenectomy
Complictions
• Delayed gastric emptying
• Pancreatic fistula
• Intra-abdominal abscess
• Operative site hge
• GI hge
Palliation of unresectable
Pancreatic adenocarcinoma
• Biliary obstruction:
� Biliary enteric bypass
� Endoscopic biliary stent
placement
�Radiographic transhepatic
stent placement
Palliation of unresectable
Pancreatic adenocarcinoma
• Gastric outlet obstruction:
�Gastroenteric bypass
� Endoscopically placed
duodenal stent
Palliative Bypass
Adjuvant therapy
• 85% local recurrence .→ RT
• 70% liver metastasis.→CT
• 5 FU is the only active agent.
• Gemcitabine.
• 5 FU + Gemcitabine
Take home message
• Surgical resection offers the only chance of long-term survival for patients with pancreatic cancer
• Patients who undergo surgical resection for localized, non-metastatic adenocarcinoma of the pancreas have a 5-year survival rate of approximately 25%
Take home message
• All patients with a suspected pancreatic neoplasm should be presented and discussed in a multidisciplinary tumor board
• Detection and the appropriate management of premalignant lesions is mandatory for decreasing mortality.