Pancreas CancerPancreas Cancer

Nimisha K. Parekh, MD, MPHNimisha K. Parekh, MD, MPHDirector, Inflammatory Bowel Disease ProgramDirector, Inflammatory Bowel Disease ProgramH. H. Chao Comprehensive Digestive Disease H. H. Chao Comprehensive Digestive Disease

CenterCenterAssistant Professor of Clinical MedicineAssistant Professor of Clinical Medicine

University of California IrvineUniversity of California Irvine

PancreasPancreas

The FactsThe Facts 38,000 Americans will be diagnosed 38,000 Americans will be diagnosed

with pancreatic cancer this yearwith pancreatic cancer this year 34,000 will die from the disease this 34,000 will die from the disease this

yearyear pancreatic cancer is the 4th leading pancreatic cancer is the 4th leading

cause of cancer-related death in the UScause of cancer-related death in the US 5-year survival rate is 5 percent5-year survival rate is 5 percent Seventy-five percent of pancreatic Seventy-five percent of pancreatic

cancer patients die within the first 12 cancer patients die within the first 12 months of the diagnosismonths of the diagnosis

The FactsThe Facts Low survival rates are Low survival rates are

due to the fact that due to the fact that fewer than 10% of fewer than 10% of patients' tumors are patients' tumors are confined to the pancreas confined to the pancreas at the time of diagnosisat the time of diagnosis

In most cases, the In most cases, the tumor has progressed to tumor has progressed to the point where surgery the point where surgery is impossible.is impossible.

Types of Pancreatic Types of Pancreatic TumorsTumors

Ductal Adenocarcinomas (85%)Ductal Adenocarcinomas (85%) Two thirds in Two thirds in head of pancreashead of pancreas

Undifferentiated carcinomasUndifferentiated carcinomas Acinar cell carcinomas (1-2%)Acinar cell carcinomas (1-2%) Sarcomatoid carcinoma/Carcinosarcoma Sarcomatoid carcinoma/Carcinosarcoma

(<1%)(<1%) Serous cystic neoplasmsSerous cystic neoplasms Mucinous cystic neoplasmsMucinous cystic neoplasms Intraductal papillary mucinous neoplasmsIntraductal papillary mucinous neoplasms NeuroEndocrineNeuroEndocrine

Who should be screened?Who should be screened?

Not everyone should be screened for Not everyone should be screened for pancreatic cancer. pancreatic cancer.

Screening makes sense for people Screening makes sense for people who are at risk for the disease who are at risk for the disease typically because of hereditary typically because of hereditary factors or genetic syndromes that factors or genetic syndromes that increase the likelihood of developing increase the likelihood of developing pancreatic cancer. pancreatic cancer.

Factors that Increase an Factors that Increase an Individual's Risk for Individual's Risk for Pancreatic CancerPancreatic Cancer

Cigarette SmokingCigarette Smoking AlcoholAlcohol BMI/ObesityBMI/Obesity Physical ActivityPhysical Activity Diabetes??Diabetes?? Gender (M>F)Gender (M>F) Family HistoryFamily History Genetic Syndromes Genetic Syndromes

associated with associated with pancreas cancerpancreas cancer

Family History Risk FactorsFamily History Risk Factors

Two or more first-degree relatives (parents, Two or more first-degree relatives (parents, sibling, child) with pancreatic cancer sibling, child) with pancreatic cancer

One first-degree relative diagnosed with One first-degree relative diagnosed with pancreatic cancer at an early age (under the pancreatic cancer at an early age (under the age of 50) age of 50)

Two or more second-degree relatives Two or more second-degree relatives (grandparent, aunt/uncle, niece/nephew, half-(grandparent, aunt/uncle, niece/nephew, half-sibling) with pancreatic cancer, one of whom sibling) with pancreatic cancer, one of whom developed it at an early age developed it at an early age

History of a cancer syndrome associated with History of a cancer syndrome associated with pancreatic cancerpancreatic cancer

Genetic Syndromes Associated Genetic Syndromes Associated with Pancreatic Cancerwith Pancreatic Cancer

Genetic SyndromeGenetic Syndrome Genetic MutationGenetic Mutation Clinical CluesClinical Clues

Hereditary Hereditary PancreatitisPancreatitis

PRSSI PRSSI History of early History of early pancreatitis pancreatitis (inflammation of the (inflammation of the pancreas) of unknown pancreas) of unknown cause cause

Breast-ovarian cancer Breast-ovarian cancer syndrome syndrome

BRCA2 BRCA2 History of breast and/or History of breast and/or ovarian cancer ovarian cancer

Hereditary Hereditary nonpolyposis nonpolyposis colorectal cancer colorectal cancer syndrome syndrome

Mismatch repair genes Mismatch repair genes Personal or family Personal or family history of early history of early colorectal cancer colorectal cancer

Familial atypical Familial atypical multiple mole multiple mole melanoma syndrome melanoma syndrome (FAMMM) (FAMMM)

CDK2NA/p16 CDK2NA/p16 Multiple melanomas Multiple melanomas with or without history with or without history of pancreatic of pancreatic malignancy malignancy

Peutz-Jeghers Peutz-Jeghers syndrome syndrome

STK11/LKB1 STK11/LKB1 Benign polyps of the Benign polyps of the gastrointestinal tract gastrointestinal tract with pigmented macules with pigmented macules on the lips, inner lining on the lips, inner lining of the cheeks, and of the cheeks, and hands/feet hands/feet

DiagnosisDiagnosis

CT ScansCT Scans MRIMRI ERCPERCP Endoscopic Endoscopic

UltrasoundUltrasound LaparascopyLaparascopy

Helical CT and Helical CT and MRI/MRCPMRI/MRCP

Helical CT and Helical CT and MRI/MRCPMRI/MRCP

MRCP: Pancreatic MRCP: Pancreatic CancerCancer

Barish, NEJM, July 1999

EUS-Guided FNAEUS-Guided FNA• Nodal stagingNodal staging

~Mediastinal: esophageal, Mediastinal: esophageal, lunglung

~Abdominal/celiac: gastric, Abdominal/celiac: gastric, pancreaspancreas

~Pelvis: rectalPelvis: rectal

• Distant MetastasisDistant Metastasis~LiverLiver~Pleural/abdominal fluidPleural/abdominal fluid~AdrenalAdrenal

Pancreatic Body MassPancreatic Body Mass

UCSF Patient – MRCP – x 2; ERCP non-diagnostic; CT negative

ERCP vs. EUS for ERCP vs. EUS for Pancreatic MassesPancreatic Masses

EUSEUS Most Sensitive Most Sensitive

(well over 90%)(well over 90%) NCI recommends NCI recommends

this over CT guided this over CT guided biopsybiopsy

ERCPERCP Diagnostic Yield Diagnostic Yield

between 40-70%between 40-70%

Image courtesy of Van Dam and Brugge, NEJM, 2003

Pancreatic Cancer - Pancreatic Cancer - DetectionDetection

Schoefer et al, Abstract 1530, DDW 2000

N Sens(%)

Spec(%)

PPV(%)

NPV (%)

Accr(%)

EUS 81 96 71 89 89 89MRI 61 72* 50 78 43 66ERCP 81 84 71 87 65 80CT 70 72* 70 83 55 71US 80 57* 83 89 45 65

EUS detected all tumors less than 2cm

Staging of Pancreas Staging of Pancreas TumorsTumors

Stage I.Stage I. Cancer is confined to the Cancer is confined to the pancreas. pancreas.

Stage II.Stage II. Cancer has spread beyond the Cancer has spread beyond the pancreas to nearby tissues and organs and pancreas to nearby tissues and organs and may have spread to the lymph nodes. may have spread to the lymph nodes.

Stage III.Stage III. Cancer has spread beyond the Cancer has spread beyond the pancreas to the major blood vessels pancreas to the major blood vessels around the pancreas and may have spread around the pancreas and may have spread to the lymph nodes. to the lymph nodes.

Stage IV.Stage IV. Cancer has spread to distant Cancer has spread to distant sites beyond the pancreas, such as the sites beyond the pancreas, such as the liver, lungs and the lining that surrounds liver, lungs and the lining that surrounds your abdominal organs your abdominal organs

TreatmentsTreatments

SurgerySurgery RadiationRadiation ChemotherapyChemotherapy Combination of Combination of

aboveabove

Anatomy of a WhippleAnatomy of a Whipple

Final PointsFinal Points

Familial Pancreatic Cancer /National Familial Pancreatic Cancer /National Familial Pancreas Tumor RegistryFamilial Pancreas Tumor Registry

Hirshberg Foundation for Pancreatic Hirshberg Foundation for Pancreatic Cancer ResearchCancer Research

NIHNIH UCLA, UCI, City of Hope have pancreas UCLA, UCI, City of Hope have pancreas

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