Transcript Pancreatic Cancer Treatment

PERIAMPULLARY TUMORS
Prof. ÖZCAN GÖKÇE, MD
Director of the Department of General Surgery
Yeditepe University Hospital
Neoplasms of the Endocrine
Pancreas
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INSULINOMA
GASTRINOMA
VIPoma
GLUCAGONOMA
SOMATOSTATINOMA
NONFUNCTIONING ISLET CELL
TUMORS
Passaro's triangle (The typical location of a gastrinoma)
Radiolabeled octreotide scan
Insulinoma
Whipple’s triad
• 1)Hypoglisemic symptoms by fasting
• 2)Episodic low blood sugar(below 50 mg/dl)
• 3)Relief of symptoms by glucose
Treatment
• Surgery
• Diazoxide
• Streptozotocin
GASTRINOMA
• (Zollinger-Ellison Syndrome)
• Symptoms
Ulcers and diarrhea
Treatment
Surgery
Acid blocking agents
Streptozotocin-5FU
VIPoma
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Verner-Morrison Syndrome…WDHA
Watery diarrhea
Hypokalemia
Achlorhydria
Pancreatic Cholera
Treatment
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Surgery
Streptozotocin
5FU
Steroids
Trifluoperazine
Somatostatin
MULTIPL ENDOCRINE
NEOPLASIA
• MEN I….3-P(Pituiatary,parathyroid,pancreas)
Autosomal dominant(11q13 coded gene)
• MEN IIA...(Pheo-Medullary tc-parathyroid tm)
• MEN IIB..(Pheo-Medullary tc-ganglioneuromas)
Mutation in ret proto-oncogene
Neoplasms of the Exocrine
Pancreas
PERIAMPULLARY
EPITHELIAL TUMORS
1)PANCREATIC CANCER
2)CANCER OF COMMON BILE DUCT
3)CANCER OF DUODENUM
4)TUMOR OF AMPULLA OF WATER
5)BENIGN TUMORS OF THE
REGION(EXTREMELY RARE)…cystadenomas
• Pancreatic cancer is one of the most
serious types of cancer occurring. It is a
disease which forms malignant or
cancerous cells in the tissues of the
pancreas.
• The digestive juices are produced by
exocrine pancreas cells and the hormones
are produced by endocrine pancreas cells.
About 95% of pancreatic cancers begin in
exocrine cells.
• Pancreatic Cancer has been called a
"silent" disease because early Pancreatic
Cancer usually does not cause symptoms.
• If the tumor blocks the common bile duct
and bile cannot pass into the digestive
system, the skin and the sclera may
become yellow (jaundiced), and the urine
darker as a result of accumulated bile
pigment called bilirubin.
Pancreatic Cancer Causes
• The exact as to what damages DNA in the vast
majority of cases of pancreatic cancer is not
clear. In other words the exact pancreatic cancer
causes are not clear. But it is known that a small
percentage of people develop the disease as a
result of a genetic predisposition. These people
who have a close relative, such as a parent or
sibling, with pancreatic cancer have a higher risk
of developing pancreatic cancer themselves.
• A number of genetic diseases have been
associated with an increased risk of pancreatic
cancer, including familial adenomatous
polyposis, nonpolyposis colon cancer, familial
breast cancer associated with the BRCA2 gene,
hereditary pancreatitis, and familial atypical
multiple mole-melanoma syndrome which is a
serious type of skin cancer. This means that
people who have a hereditary predisposition to
develop these cancers are also more likely to
develop pancreatic cancer.
• Although the above causes are evident
only 10 percent of pancreatic cancers
result from an inherited tendency. A
greater number are caused by
environmental or lifestyle factors, such as
smoking, diet and chemical exposure.
• Age: is also a factor to be
considered which increases the
incidence of the disease. As age
increases the probability of
pancreatic cancer also increases.
The incidence of Pancreatic Cancer
is relatively low in individuals up to
age 50, after which it increases
significantly. The age group 65 - 79
has the highest incidence of
Pancreatic Cancer.
• Smoking increases the
chances of developing
Pancreatic Cancer. Study
reveals that smokers develop
Pancreatic Cancer more than
twice as often as nonsmokers.
• Non vegetarians have a high
risk of getting Pancreatic
Cancer, if the intakes of meat
& fat are high.
• Medical factors such as
cirrhosis (a chronic liver
disease), chronic pancreatitis,
diabetes and a history of
surgery to the upper digestive
tract also contribute to the risk
• Environmental factors such
as long-term exposure to
certain chemicals, like
gasoline and related
compounds, as well as certain
insecticides, may increase the
risk of developing Pancreatic
Cancer.
• Genetic predisposition
should also be considered as
the possible reason to
increase the risk. Possibly
10% of cases of Pancreatic
Cancer are related to genetic
disorders.
• Pancreatic Cancer Stage
• To apt for any treatment option the doctor
has to know the exact stage of the
pancreatic cancer in the patient. Tests and
procedures to stage pancreatic cancer are
usually done at the same time as
diagnosis.
• The following are pancreatic cancer stage
descriptions:
• Stage 0: In this stage the cancer is found
only in the lining of the pancreas. Stage 0
is also called carcinoma in situ.
• Stage I: Cancer is found only in the
pancreas in this stage. This stage further
divided into stage IA and stage IB, based
on the size of the tumor.
• Stage IA: The tumor is 2 centimeters or
smaller.
• Stage IB: The tumor is larger than 2
centimeters.
• Stage II: Cancer may have spread to nearby
tissue and organs, and may have spread to
lymph nodes near the pancreas in this stage.
This stage is further divided into stage IIA and
stage IIB, based on where the cancer has
spread.
• Stage IIA: Cancer has spread to nearby tissue
and organs but has not spread to nearby lymph
nodes.
• Stage IIB: Cancer has spread to nearby lymph
nodes and may have spread to nearby tissue
and organs.
• Stage III: Cancer has spread to the
major blood vessels near the
pancreas and may have spread to
nearby lymph nodes in this stage.
(Beyond this point the patient is
surgically incurable)
• Stage IV: Cancer may be of any size and
has spread to distant organs, such as the
liver, lung, and peritoneal cavity. It may
have also spread to organs and tissues
near the pancreas or to lymph nodes.
Pancreatic Cancer Symptoms
• Discomfort in abdomen or Upper abdominal pain that
may radiate to the middle or upper back
• Yellowing of the skin and the sclera (jaundice)
• Itching
• Nausea and vomiting
• Digestive problems
• Weight loss
• Fatigue
• Loss of appetite
• Glucose intolerance
• Malnutrition.
• In addition, the pancreas may
produce too much insulin, causing
such symptoms as dizziness,
weakness, diarrhea, chills, or
muscle spasms.
• The patient may not even notice
the gradual onset of these
relatively nonspecific symptoms.
The doctor may interpret them as
being caused by something else.
Therefore one should be very
careful if any of the above
symptoms are experienced.
Pancreatic Cancer Treatment
• The choice of Pancreatic Cancer
treatment depends largely on the stage
the pancreatic cancer in the patient.
• Possible treatments include surgery,
chemotherapy, radiation, and biological
therapy. Biological therapy is also known
as immunotherapy.
Surgery
• During diagnosis, only about 20% of pancreatic
tumors can be removed by surgery. This option
is usually reserved for Stage 1 patients whose
cancer is resectable. The surgeon may perform
a resection, which is the removal of a small part
of the pancreas.
• The standard procedure is called a
pancreaticoduodenectomy (Whipple
procedure).This surgery for Pancreatic Cancer
should be done at centers that perform the
procedure frequently. It is the more extensive
surgery which is the removal of the pancreas
head and nearby structures such as the
duodenum. It might be necessary to remove the
entire pancreas as well as the spleen,
gallbladder, and bile duct.
• When the tumor is confined to the
pancreas but cannot be removed, a
combination of radiation therapy and
chemotherapy may be recommended.
Radiation therapy
• Certain substances emit invisible, high-energy rays, or radiation.
These substances are called radioactive. The energy of the rays can
kill cells. Special machines aim the rays at the parts of the body with
cancerous tumors, so as to kill the cancer cells while minimizing
damage to healthy tissue.
• Unlike chemotherapy, radiation is not necessarily carried throughout
the body. As such, it is known as a local therapy, rather than as a
systemic therapy. However, there are still potential side effects of
radiation including fatigue, localized hair loss, changes to
appearance of skin, and digestive problems. Medicines and other
treatments can reduce the intensity of the side effects. As with other
cancer treatments, the incidence of side effects varies with patient
health and the exact nature of the treatment.
Chemotherapy
• When the tumor has spread to other organs
(metastasized) such as the liver, chemotherapy alone is
usually used.
• The standard chemotherapy agent is gemcitabine, but
other drugs may be used. Gemcitabine provides clinical
improvement in approximately 25% of patients.
For patients who have biliary obstruction (blockage of
the vessels that transport bile) and the tumor cannot be
totally removed, the obstruction must be relieved. There
are generally two approaches to this, surgery and
placement of a biliary stent (similar to stents placed in
the arteries of the heart to relieve blockages) during
ERCP.
Immunotherapy
• This form of therapy involves using drugs to boost the
body's natural immune response (its ability to fight
disease). Examples of these drugs are interferon and
monoclonal antibodies. They work with the body's
immune system to block the growth of cancer cells.
Biological therapy can be used on its own or in
conjunction with other therapies.
Immunotherapy can result in side effects that are
reminiscent of the flu: fever, aches, weakness, fatigue,
and chills. Patients may also experience skin problems
such as easy bruising or rashes, as well as diarrhea and
nausea.
Pancreatic Cancer Survival Rate
• Pancreatic Cancer is rarely curable. The overall
pancreatic cancer survival rate is less than 4%.
The cure rates are highest (although still usually
under 25%) if the tumor is small (less than 2 cm
in diameter) and is truly localized to the
pancreas but, unfortunately, such cases account
for fewer than 20% of all cases of Pancreatic
Cancer. For patients with advanced cancers, the
overall survival rate of all stages is less than 1%
at 5 years with most patients dying within 1 year.
Prognosis of periampullary tumors
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5-year survival rate
Pancreas…………...............%10
Ampulla of Vater…………...% 35
Duodenum………………….% 30
Bile duct…………………….% 15
• After Whipple operation(without lymph
node metastases)…………..% 35
CYSTIC NEOPLASMS OF THE
PANCREAS
MUCINOUS CYSTADENOMA AND CYSTADENOCARCINOMA
CYSTADENOMA