PANCREATIC CANCER

PANCREATIC CANCER

– DUCTAL ADENOCARCINOMAS (90%)– ISLET CELL TUMORS– NEUROENDOCRINE TUMORS

– Head of the pancreas – frequent site

PANCREATIC CANCER

• 72 years old – median age of diagnosis• 65-84 years old – peak incidence• Males > Females

• Risk Factors: • Cigarette Smoking, Obesity, Non-hereditary Chronic

Pancreatitis• Environmental Factors (diet, coffee), previous partial

gastrectomy or cholecystectomy and H. pylori

CLINICAL FEATURES

• Common presenting symptoms– Pain

• More of a problem with lesions in the body or tail• Dull ache in the upper abdomen radiating to the back and may

characteristically improve upon leaning forward• Intermittent and may worsen with meals

– Obstructive Jaundice• pruritus, pale stools and dark urine

– Weight loss• Anorexia, early satiety, malabsorption or diarrhea/steatorrhea

– Anorexia

PHYSICAL FINDINGS

• (+) Courvoisier’s sign• Palpable, nontender gallbladder

• (+) Virchow’s Node• Advanced Disease

• Abdominal Mass, Hepatomegaly, Splenomegaly, Ascitis

DIAGNOSTIC PROCEDURES• Ultrasound• CT scan

– Show pancreatic mass, dilatation of the biliary system or pancreatic duct, distal spread to the liver, regional lymph nodes or peritoneum

• ERCP– Stricture or obstruction, obtain brushings of a stricture for

cytology or for placing stents• Endoscopic Ultrasound

– Small lesions (<2-3cm), local staging• MRCP

– Defines anatomy of the pancreatic duct and biliary tree• FDG-PET

– Excluding occult distal metastasis

CA 19-9

• Serum Marker• 80-90% sensitivity and specificity• Suggestive of the diagnosis of pancreatic cancer

– May be elevated in patients with jaundice without pancreatic cancer

• Prognostic impilcations– Very high levels with inoperable disease

• Serial evaluation is useful for monitoring response to treatment• Detecting recurrence in patients with completely

resected tumors

TREATMENT

• Symptom management• Advanced Pancreatic Cancer

• With metastatic or locally advanced inoperable disease and are the majority with newly diagnosed disease

– Endoscopic biliary or duodenal stenting– Intestinal bypass surgery– Deoxycytidine analogue Gemcitabine

• Single agent 1,000 mg/m2 weekly for 7 weeks followed by 1 week rest then weekly for 3 weeks every four weeks thereafter

• Median survival – 6 months, 12 months (18%)

TREATMENT

• Operable Disease– Complete surgical resection (Stage I or II) with

distant metastases excluded by prior CT is potentially curative

– Lymph node-negative disease, smaller tumors (<3cm) negative resection margins and well-differentiated tumors

– Surgery preceded by laparoscopy• To exclude peritoneal metastases

TREATMENT

• WHIPPLE PROCEDURE/ Pancreaticoduodenectomy– Standard operation for cancers of the head or

uncinate process of the pancreas.– Involves resection of the pancreatic head,

duodenum, 1st 15cm of jejunum, common bile duct, and gallbladder and a partial gastrectomy, with the pancreatic and biliary anastomosis placed 45 – 60 cm proximal to the gastrojejunostomy

PATIENT CHOLANGIO-CARCINOMA

GB CA CA OF THE AMPULLA OF VATER

BENIGN LIVER TUMORS

PANCREATIC CANCER

65 Y/O MALE +

JAUNDICE + + +

12mm CBD WITH DILATED INTRAHEPATIC DUCTS

+ +

ALT 165IU/ml

ALP 325 mg/dl

TOTAL BILIRUBIN 3mg/dl

PREVIOUS CHOLECYSTECTOMY

+ + +

SMOKER +

DRINKS 2 BOTTLES OF BEER ONCE A WEEK

OBESE +

TREATED FOR TB