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Câncer de pâncreas Câncer de pâncreas e vias biliarese vias biliares
IncidênciaMortalidade
5ª causa de morte por câncer na América do Norte no ano de 2000
Câncer pancreáticoCâncer pancreáticoEpidemiologiaEpidemiologia
Pancreatite crônicaDiabetes MelitusAnomalias na junção dos ductos
biliopancreáticosHábito de fumarConsumo de café
Câncer pancreáticoCâncer pancreáticoGrupos de riscoGrupos de risco
ClínicoIcterícia – 50%Dor lombarPerda de pesoDiminuição do apetite
Câncer pancreáticoCâncer pancreáticoDiagnósticoDiagnóstico
ClínicoSinal de curvoisier-terrier
Câncer pancreáticoCâncer pancreático
DiagnósticoDiagnóstico
LaboratorialCA 19-9
DiagnósticoPrognósticoMonitoração
Câncer pancreáticoCâncer pancreáticoDiagnósticoDiagnóstico
ImagenológicoUS abdome superiorTC abdome superior
Câncer pancreáticoCâncer pancreáticoDiagnósticoDiagnóstico
TomográficosArtéria mesentérica superior livreVeia mesentérica superior livreTronco celíaco livre
Câncer pancreáticoCâncer pancreáticoCritérios de ressecabilidadeCritérios de ressecabilidade
Intra hepáticasExtra hepáticasVesícula biliar
Vias biliaresVias biliares
ImagenológicoUS abdome superiorTC abdome superiorEndoscopia digestiva alta com
duodenoscopia
TumoresTumoresperi-ampolaresperi-ampolares
DiagnósticoDiagnóstico
protocolo padrãoQU IMIO e R AD IO
protocolo alternativo
R ESSEC Ç ÃOcom linfadenectomia
C IRU R GIA
D R EN AGEMB ILIAR
PER C U TÂNIA
bilirrubina total> 20 mg/dl
bilirrubina total< 20 mg/dl
preparo paracirurgia
critérios deR ESS EC AB ILID ADE
D ER IVAÇ ÃOB ILIODIGESTIVAcom biópsia com
congelação
condição clínicaB OA
PR OTOC OLOALTER N ATIVO
FPT
AV ALIAÇ ÃOON C OLÓGICA
PR ÓTESEEN D OSC ÓPIC Acom biópsia ou
escovado
DR EN AGE ME XTE RN A
*
R TD ESOB STRU TIVA
*
condição clínicaR U IM
critérios deIR RESSEC AB ILID AD E
D IAGN ÓSTIC O:sugestivo de N E OPLASIA
C PR E
DIAGN ÓSTICO:sugestivo de doença
B EN IGN A
U Sendoscópica
ED Acom duodenoscopia
TCabdome superior
U LTR ASON OGRAFIAAB DOMIN AL
C OLESTASEEXTRA-H EPÁTIC A
TNM
Câncer pancreáticoCâncer pancreáticoEstadiamentoEstadiamento
CirúrgicoOperação de Whipple
LinfadenectomiaRadioterápicoQuimioterápico
Câncer pancreáticoCâncer pancreáticoTratamentoTratamento
IncidênciaMortalidade
Câncer de vesícula Câncer de vesícula biliarbiliar
EpidemiologiaEpidemiologia
SuspeitoInaparente
Câncer de vesícula Câncer de vesícula biliarbiliar
DiagnósticoDiagnóstico
CirúrgicoColecistectomia simplesColecistectomia com:
Segmentectomia hepática IV e VLinfadenectomia regional
Câncer de vesícula Câncer de vesícula biliarbiliar
TratamentoTratamento
Câncer pancreáticoCâncer pancreático
PrognósticoPrognóstico
Câncer de vesícula Câncer de vesícula biliarbiliar
PrognósticoPrognóstico
The anatomic triangle in which approximately 90% of gastrinomas are found. (From Stabile BE, Morrow DJ, Passaro E Jr: The gastrinoma triangle: Operative implications. Am J Surg 147:25-31, 1984.)
Bismuth classification of perihilar cholangiocarcinoma by anatomical extent. Type I tumors (upper, left) are confined to the common hepatic duct, and type II tumors (upper, right) involve the bifurcation without involvement of secondary intrahepatic ducts. Type IIIa and IIIb tumors (lower, left) extend into either the right or left secondary intrahepatic ducts, respectively. Type IV tumors (lower, right) involve the secondary intrahepatic ducts on both sides.
Endoscopic retrograde cholangiogram demonstrating a perihilar cholangiocarcinoma involving secondary intrahepatic branches on the right as well as the common hepatic duct. The left hepatic duct is not visualized.
CAUSES AND RISK FACTORS• Increasing age• Smoking• Chronic pancreatitis• Hereditary pancreatitis• Familial pancreatic cancer• Familial excess of pancreatic cancer (FEPC)RECOMMENDATIONS• Continued health education to avoid tobacco consumption shouldlower the risk of developing pancreatic cancer• Continued health education to avoid excess alcohol consumptionshould lower the risk of developing chronic pancreatitis• All patients with an increased inherited risk of pancreatic cancershould be referred to a specialist center offering specialist clinicaladvice and genetic counseling, and where appropriate genetictesting such as for BRCA2 mutations
TABLE 73.1 HEREDITARY CANCER SYNDROMES AFFECTINGTHE PANCREASSyndrome Gene defect/affectedchromosomeHereditary nonpolyposis colon cancer Defective DNA mismatch(HNPCC) repair enzymesFamilial atypical multiple mole p16melanoma (FAMMM)Familial breast cancer BRCA2Ataxia telangiectasia ATMvon Hippel-Lindau disease VHLHereditary pancreatitis PRSS1Familial pancreatic cancer 4q32–34 ?Li-Fraumeni syndrome p53Cystic fibrosis 7q31Familial adenomatous polyposis (FAP) 5q12–21Peutz-Jeghers syndrome STK11
TABLE 73.2 HISTOLOGICAL VARIANTS OF MALIGNANT TUMORS OF THE EXOCRINE PANCREAS
Histological type Frequency Features
Ductal adenocarcinoma 82% Long-term survival rare
Anaplastic 5% Worse prognosis than ductal
Mucinous cystadenocarcinoma 3% Better prognosis than ductal
Acinar cell 2% Poor prognosis
Mucinous noncystic 2% –
Adenosquamous 2% Poor prognosis
Small cell 1% Extremely poor prognosis
Squamous cell carcinoma <1% More aggressive than ductal
Intraductal papillary-mucinous <1% More favorable prognosis then ductal
Serous cystadenocarcinoma Rare Prognosis similar to ductal
Pancreatoblastoma Rare Childhood tumor
CLINICAL PRESENTATION• Symptoms• Painless jaundice• Weight loss• Back pain• Late onset diabetes mellitus• Acute/chronic pancreatitis• Acute cholangitis• Duodenal obstruction• Deep vein thrombosis• Signs• Jaundice• Hepatomegaly• Palpable gallbladder (Courvoisier’s sign)• Cachexia• Troisier’s sign (Virchow’s node)• Abdominal mass• Ascites
DIFFERENTIAL DIAGNOSIS OF A PANCREATIC MASS• Duodenal carcinoma• Ampullary carcinoma• Cholangiocarcinoma• Neuroendocrine tumor• Endocrine tumor• Chronic pancreatitis• Cystadenoma• Anaplastic cancer• Mucinous cystadenocarcinoma• Acinar cell• Mucinous noncystic• Adenosquamous• Small cell• Squamous cell carcinoma• Intraductal papillary-mucinous• Serous cystadenocarcinoma• Pancreatoblastoma• Metastatic tumor• Tuberculous mass• Lymphoma
DIAGNOSTIC METHODSTransabdominal ultrasoundContrast-enhanced computerized tomography (CE-CT) scanSpiral CT scanMagnetic resonance imaging scan (MRI)Magnetic resonance cholangiopancreatography (MRCP)Positron emission tomography (PET) scanEndoscopic ultrasound (EUS)Endoscopic cholangiopancreatography (ERCP)LaparoscopyLaparoscopic ultrasound