Transcript PANCREATIC CANCER

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 welldifferentiated 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
CHOLANGIOCARCINOMA
GB CA
CA OF THE
AMPULLA
OF VATER
65 Y/O MALE
BENIGN LIVER PANCREATIC
TUMORS
CANCER
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JAUNDICE
+
12mm CBD WITH
DILATED INTRAHEPATIC
DUCTS
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+
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ALT 165IU/ml
ALP 325 mg/dl
TOTAL BILIRUBIN 3mg/dl
PREVIOUS
CHOLECYSTECTOMY
SMOKER
+
+
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DRINKS 2 BOTTLES OF
BEER ONCE A WEEK
OBESE
TREATED FOR TB
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