Diagnosticul Tumorilor Solide Ale Pancreasului Exocrin(1)
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Transcript of Diagnosticul Tumorilor Solide Ale Pancreasului Exocrin(1)
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U.M.F. GR.T. POPA IASI
`
The neoplasia of the digestive
tube: the diagnostic of the solidetumors of the exocrine pancreas
Author: Tibuleac Alexandra
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The neoplasis of the digestive tube arefrequently diagnosed in advanced
stages when the oncological treatmentis hard to approach.The diagnosis ismade sometimes by chance, due to
some other medical conditions.
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One of the most difficult neoplasia ofthe digestive tube to identify is the
solid tumor of the exocrine pancreas,as it is usually diagnosed in advancedstages.
Another issue that interferes with thediagnose of this kind of tumor is thefact that many times it can be
confused with the psedotumoral formof the chronic pancreatitis.
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Chronic pancreatitis- pseudotumoral
form
Chronic pancreatitis is commonly definedas a continuing chronic inflammatoryprocess of the pancreas, characterized byirreversible morphological changes. Thischronic inflammation can lead to chronicabdominal pain and/or impairment ofendocrine and exocrine function of the
pancreas.
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The neoplasia of the exocrine
pancreas
Ductal carcinoma represents 90% of the exocrinetumors i75% of all malignant tumors of pancreas.
Kevin G. Burnand, Anthony E. Young - TheNew AirdsCompanion in Surgical Studies2-nd edition, 1999,pag.962-963;
The fifth cause of mortality through cancer in men(after lung, colon and prostate cancer)
Isselbacher, Fauci, Braunwald, Martin, WilsonHarrisonEdiiaa 14-a,Editura Teora, 2004
The fifth cause of mortality through cancer inwomen( after breast, lung, colon, genital cancer)
Isselbacher, Fauci, Braunwald, Martin, WilsonHarrisonEdiiaa 14-a,Editura Teora, 2004
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Material and method
The study is based on the analyze of
cases from the third hospital ofsurgery, in the period January 2000 December 2004.
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Material and method
798 cases with
pancreatitis affections
91 cases pseudotumoralform
of the chronic pancreatitis
212 cases of neoplasia
of the exocrine pancreas
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Material and method
Demographic parameters
Risk factors
Date clinice
Date paraclinice (de laborator, imagistice,
anatomie patologic)Controale postoperatorii
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Sex distribution of the pseudotumoral
form of the chronic pancreatitis
Women
27%
Men
73%
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Demographic distribution of the pseudotumoral
form of the chronic pancreatitis
Rural
areas
40%
Urban
areas
60%
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Age and sex distribution of the pseudotumoral
form of the chronic pancreatitis
0
2
4
6
8
10
12
14
80
Women Men
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Bad habits for the patient with the
pseudotumoral form of the chronic pancreatitis
Alcohol
27%
tobacco
8%
Tutun&
Alcool
27%
Denies theuse of
alcohol
38%
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Ponderea antecedentelor personale
patologice n pancreatita cronic
pseudotumoral
8%
5%3%
26%
18%
40%
Ulcer duodenal
Pseudochist
Ulcer duodenal&Hepatita cronica
Pancreatita acuta
Pancreatita acuta&
Pseudochist
Diabet zaharat
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Localizarea durerii n pancreatita
cronicpseudotumoral
Durere in
hipocondrul
stang
7%
Durereabdominala
superioara
25%
Durere
iradiata
posterior
9%
Durere in
hipocondrul
drept
21%
Durereepigastrica
38%
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Simptomele asociate durerii n
pancreatita cronicpseudotumoral
Scadereponderala
29%
Greturi&
Varsaturi
23%
Icter
16%
Scaune acolice
8%
Astenie
24%
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Imagistica in diagnosticul
pancreatitei cronice pseudotumorale
Anul Nr.pacienti ECHO CT IRM ERCP
2000 22 19 3 0 4
2001 5 2 5 0 1
2002 15 13 6 4 0
2003 8 8 3 0 0
2004 13 13 10 2 0
Total 63 5587%
2743%
69,5%
58%
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DISTRIBUIA PE SEXE A
NEOPLASMULUI PANCREASULUI
EXOCRIN
Sex feminin
49%
Sex
masculin51%
In conformitate cu datele prezentate de :
Andren-Sandberg A.Demographics of exocrine pancreatic cancer with special reference to age, sex and time tends, Int J Pancreatol, 1993; 214-6
Backman PL, Barlow L, Andren-Sandberg ADecreasing incidence of exocrine pancreatic cancer in Sweden, Int J Pancreatol 1995;18:289-90.
Bourhis J, Lacaine R, Augusti M, Huguier MProtective effect of estrogen in pancreatic cancer, Lancet, 1987.
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Distribuia demografica
neoplasmului de pancreas exocrin
RURAL
53%
URBAN
47%
Maruchi N, Brian D, Ludwig JCancerof the pancreas in Olmsted County,Minnesota, 1935-1974, Mayo Clin Proc, 1979; 54:245-9.Royall D, Jeejeebhoy KN, Taylor BRNutritionalstatus and function in patients following Whipple procedure compared with controls,J Am Coll Nutr, 1996; 15:73-8.
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Distributia pe grupe de varsta si sex a
pacientilor cu neoplasm de pancreas
exocrin
0
5
10
15
20
25
30
35
40
80
Sex feminin Sex masculinIn conformitate cu :Maruchi N, Brian D, Ludwig JCancerof the pancreas in Olmsted County,Minnesota, 1935-1974, Mayo Clin Proc, 1979; 54:245-9.
Smith PE, Krementz ET, Reid RJAnanalysis of 600 with carcinoma of the pancreas,Surg Gynecol Obstet, 1967, 124:1288-96.Pitt HACurativetreatement for pancreas neoplasms. Standard resection,Surg Clin North Am, 1995; 75:891-904.
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Distribuia factorilor de risc ai
neoplasmului pancreasului exocrin
Alcool
21%
Tutun
5%Neaga
consumul
57%Tutun &
Alcool
17%
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Sediul durerii n neoplasmul de
pancreas exocrin
0
10
20
30
40
50
60
70
Epigastric
Hipocondrustang
Hipocondrudrept
Abdominalsuperior
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Simptome asociate durerii n
neoplasmul de pancreas exocrin
Simptom Nr.Cazuri Procente(%)
Urini hipercrome &
scaune acolice
52 12,35
Greuri & vrsturi 50 11,87
Icter 105 24,94
Prurit 39 9,29
Scdere ponderal 102 24,22
Astenie & inapeten 73 17,33
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The pseudotumoral form of the
chronic pancreatitis
In population studies, males are affectedmore commonly than females (6.7 vs 3.2 per100,000 population).
Rates in males peak at age 45-70 years andthen decline; female rates reach a plateau,which remains stable after age 35 years.
Sex differences with respect to etiology also
exist. Alcohol-induced illness is moreprevalent in males, idiopathic andhyperlipidemic-induced pancreatitis is moreprevalent in females, and equal sex ratios areobserved in chronic pancreatitis associated
with hereditary pancreatitis.
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The neoplasm of the exocrine
pancreas
affects in equal proportions both men andwomen, despite the area from which theybelong (urban/rural);
the angle of incidence is between 60-80 yearsold;
At women the incidence grows aftermenopause (the protective role of estrogen);
The diagnose is late because the primarysymptoms, abdominal pain and jaundice,appear in the advanced stages of the illness;
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The neoplasm of the exocrine
pancreas
At the point of diagnose, 90% of the pacientsare already in the state of ganglionic,lymphatic invasion and/or metastatic;
It can have as a first sign the debut of thediabetului zaharat, after 60 years or more,without obesity and with a fast evolutiontowards the insulin dependence;
the tumore manifests when it has largedimensions, extension in nearby tissues andmetastasis, and it can not be , usually,resected ;
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Neoplasmul de pancreas exocrin
ecographie has its limits: only to 69,42% ofthe pacients the echo investigation helped toidentify the tumorale system;
explorarea intraoperatorie rmne metodacea mai bunde diagnostic, stadializare ideapreciere a rezecabilitii;
ecografia intraoperatoriear trebui sintre n
arsenalul uzual al oricreiinterveniin sferapancreatic. Combinat cu explorareamanualreprezintmetoda cu cea mai mareacurateediagnostic.
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Pancreatita cronic pseudotumoral
vs neoplasmul pancreasului exocrin
diagnosticul diferenial ntre pancreatita
cronic pseudotumoral i neoplasmul de
pancreas exocrin este dificil de realizat chiarsi computer tomografic;
computer tomografia rmne nsa cea mai
important metod imagistic ce poate da
relaii asupra tumorii, raporturilor acesteiacu structurile nvecinate, adenopatiilor,
metastazelor hepatice.
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Pancreatita cronic pseudotumoral
vs neoplasmul pancreasului exocrin
endoscopia retrograd colangiopancreaticeste metoda golden standard pentrulocalizarea cefalic a tumorilor solidepancreatice cu rsunetasupra cilorbiliare ipancreatice,
rezonan magnetic imagistic are o
contribuia limitat n diagnosticuldiferenialal tumorilor solide pancreatice iarcosturile relativ crescute o fac s nu fieutilizatde primintenie.
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Pancreatita cronic pseudotumoral
vs neoplasmul pancreasului exocrin
Rezonanamagneticcolangiopancreatografic(MRCP) este o noumetod neinvaziv de diagnostic a
modificrilor ductului pancreatic, biliar i aorganelor adiacente n diferite axe.
Puncia biopsie intraoperatorie, eventualghidat ecografic, poate trana diagnosticulanatomopatologic n prezena unei masetumorale pancreatice, chiar daca este grevatde unele riscuri iaccidente