Pancreatic CancerPancreatic Cancer

L. OkolicsanyiG. Morana

Pancreas CancerPancreas Cancer

2nd most common GI malignancy 30,000 cases per year in US 25,000 deaths per year 4th leading cause of death in both men and

women Incidence slowly rising M>F (1.3:1) Rare before 45 yrs

Pancreas CancerPancreas Cancer EtiologyEtiology Diabetes mellitus Diet: Nitrosamines, Animal fat Cigarettes Hereditary predisposition (Hereditary

pancreatitis) Family cancer syndromes (e.g., Peutz-

Jeghers, Von Hippel-Lindau, Gardner’s) Benign disease: Chronic pancreatitis,

Intraductal papillary mucinous neoplasms

Normal Pancreas

Pancreatic TumorsPancreatic Tumors

Epithelial– Ductal epithelium (adenocarcinoma and others)– Cystic neoplasms, serous or mucinous

Endocrine– Islet cell tumors, carcinoid tumors

Exocrine– Acinar cell carcinoma

Mesenchymal-Rare

Risk Factors for Pancreatic Risk Factors for Pancreatic CancerCancer

Gene Pancreatic Cancer

(%)

Colorectal Cancer

(%)

p16 95 0

K-ras 90 50

p53 75 60

DPC4 55 15

BRCA2 7 ?

Relevance of Genetic Mutations in Pancreatic CancerRelevance of Genetic Mutations in Pancreatic Cancer

Pancreas CancerPancreas CancerClinical FeaturesClinical Features Weight loss Head:

– Painless jaundice– Gastric outlet obstruction

Body & Tail– Pain– Diabetes mellitus without family history

Metastasis: Hepatomegaly, ascites, Virchow’s (left supraclavicular) node, Trousseau’s syndrome (migratory superficial thrombophlebitis)

Pancreas CancerPancreas CancerCourvoisier’s lawCourvoisier’s law

“In the presence of jaundice a palpable gall bladder is unlikely to be due to stone”

Pancreas CancerPancreas CancerInvestigationsInvestigations Laboratory tests:

– LFT’s– CA 19-9

Radiologic tests:– Ultrasound– CT scan + biopsy– ERCP + biopsy– EUS + biopsy

Algorithm for diagnosis and staging of Pancreatic CancerAlgorithm for diagnosis and staging of Pancreatic Cancer

FNAC

Pancreas CancerPancreas CancerTreatmentTreatment Curative:

– Resection if possible– Unresectable if metastasis or major vessel

involvement– Whipple procedure for head (radical

pancreatoduodenectomy)– Distal pancreatectomy for body & tail

Palliative:– Bypass– Stent

Actuarial Survival after Actuarial Survival after Pancreatico- duodenectomyPancreatico- duodenectomy

Pancreas CancerPancreas CancerSurvival at 5 yrsSurvival at 5 yrs

Head of Pancreas 5-15% Body & Tail of pancreas 2% Distal CBD 15-35% Ampulla 30-65%

Mild improvement with adjuvant therapy

Pancreas CancerPancreas Cancer