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