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.