Pancreatic cancerPancreatic cancer

WU JIAN WU JIAN

Department of hepatobiliary Surgery Department of hepatobiliary Surgery

First Affiliated HospitalFirst Affiliated Hospital

Zhejiang University School of MedicineZhejiang University School of Medicine

INTRODUCTIONINTRODUCTION Significant increaseSignificant increase Difficult early diagnosis, difficult surgical Difficult early diagnosis, difficult surgical

resection poor prognosisresection poor prognosis 9090 ％ ％ patients die within 1 year after patients die within 1 year after

diagnosisdiagnosis 5 year survival rate 15 year survival rate 1 ％ －％ － 33 ％ ％ (lowest in (lowest in

malignancy)malignancy) Common in pancreatic headCommon in pancreatic head ，， about 2/3about 2/3

INTRODUCTIONINTRODUCTION DuctalDuctal Adenocarcinoma accounts for about Adenocarcinoma accounts for about 9090 ％％

of pancreatic neoplasms,of pancreatic neoplasms, At the time of diagnosis more than 85 per cent of At the time of diagnosis more than 85 per cent of

these tumours have extended beyond the limits of these tumours have extended beyond the limits of the organthe organ Perineural invasion Perineural invasion Lymphatic spreadLymphatic spread Extralymphatic involvement are the liver and Extralymphatic involvement are the liver and

peritoneum.peritoneum.

Manifestation of Manifestation of Pancreatic CancerPancreatic Cancer Pain or fullness in epigastriumPain or fullness in epigastrium Jaundice, itchyJaundice, itchy

Dark urine, light stoolDark urine, light stool weight loss, fatigueweight loss, fatigue GI symptomGI symptom OthersOthers

Diabetes mellitusDiabetes mellitus An episode of acute pancreatitisAn episode of acute pancreatitis

Physical Signs Physical Signs JaundiceJaundice Non-tender gallbladderNon-tender gallbladder ( (Courvoisier's signCourvoisier's sign

) ) In advanced disease ( indicative of an unresIn advanced disease ( indicative of an unres

ectable tumour )ectable tumour ) Ascites Ascites Palpable mass.Palpable mass.

Strong Suspicion of Pancreatic CancerStrong Suspicion of Pancreatic Cancer

Pain in epigastrium or back in recent two yePain in epigastrium or back in recent two ye

arsars

Recent GI symptom, negative GI testRecent GI symptom, negative GI test

Obstructive jaundiceObstructive jaundice

Unexplained weight lossUnexplained weight loss

Unexplained pancreatitisUnexplained pancreatitis

Unexplained diabetes mellitusUnexplained diabetes mellitus

Serum Tumor MarkerSerum Tumor Marker

CA199, CA50, CEA , CA242, PCAA, PaA, CA199, CA50, CEA , CA242, PCAA, PaA,

SPAN-1 Dupan for markersSPAN-1 Dupan for markers

K-ras geneK-ras gene

Poor sensitivity and specificityPoor sensitivity and specificity

Combined testCombined test

Image findingsImage findings

UltrasonographyUltrasonography Computerized tomographyComputerized tomography (CT)/spiral CT (CT)/spiral CT Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)

has no advantage over CThas no advantage over CT

Endoscopic ultrasonographyEndoscopic ultrasonography Endoscopic retrograde cholangiopancreatographyEndoscopic retrograde cholangiopancreatography (ERCP) (ERCP)

Magnetic resonance cholangiopancreatography (Magnetic resonance cholangiopancreatography (MRCP)MRCP) Percutaneous transhepatic cholangiographyPercutaneous transhepatic cholangiography (PTC) (PTC) AngiographyAngiography Positron Emission TomographyPositron Emission Tomography(PET)(PET)

CT

CT

CT

MRCP

MRCP

Patient 1Patient 1

Patient 1Patient 1

Patient 1Patient 1

Patient 2Patient 2

Patient 2Patient 2

Patient 2Patient 2

Patient 2Patient 2

EndoscopyEndoscopy

ERCPERCP

Cytology in Pancreatic juiceCytology in Pancreatic juice

Tumor markerTumor marker

Gene detectionGene detection

Combination between Endoscope Combination between Endoscope and Ultrasonographyand Ultrasonography

Endoscopic US (EUS) Endoscopic US (EUS)

Intra-duct US (IDUS)Intra-duct US (IDUS)

TreatmeTreatmentnt Radical resection is the only effective tRadical resection is the only effective t

herapy optionherapy option pancreatoduodenectomypancreatoduodenectomy

Cholecystojejunostomy, choledochojejCholecystojejunostomy, choledochojejunostomyunostomy

GastrojejunostomyGastrojejunostomy ChemotherapyChemotherapy RadiotheraptyRadiotherapty Gene therapyGene therapy ImmnotherapyImmnotherapy

Radical ResectionRadical Resection

PancreatoduodenectomyPancreatoduodenectomy （（ PDPD ）） Whipple operationWhipple operation

Child operationChild operation

Total pancreatectomyTotal pancreatectomy

Regional pancreatectomyRegional pancreatectomy

Pylorus-preserving pancreatoduodenectomyPylorus-preserving pancreatoduodenectomy (PPPD) (PPPD)

P 656

Operation ChoiceOperation Choice

Regional pancreatectomyRegional pancreatectomy Severe operation traumaSevere operation trauma Result is not confirmedResult is not confirmed Remain to be verifyRemain to be verify

PPPDPPPD Stomach is preservedStomach is preserved LN around pylorus can not be resectedLN around pylorus can not be resected Mainly in ampullary tumorMainly in ampullary tumor

Common PointCommon Point

Basic operation: PDBasic operation: PD

Standard operation: PD + D2 lymphStandard operation: PD + D2 lymph

adenectomyadenectomy

Cancer invades to vesselCancer invades to vessel

resection of portal vein or SMAresection of portal vein or SMA

Palliative ProceduresPalliative Procedures Biliary or GI obstruction Biliary or GI obstruction Ameliorate the quality of survivalAmeliorate the quality of survival Not elevate survival rateNot elevate survival rate Operation methodsOperation methods

CholedochojejunostomyCholedochojejunostomy GastrojejunostomyGastrojejunostomy JejunojejunostomyJejunojejunostomy GastrojejunostomyGastrojejunostomy

choledochojejunostomycholedochojejunostomygastrojejunostomygastrojejunostomy

Microinvasive SurgeryMicroinvasive Surgery

Relieve pain, reduce hospital time, reRelieve pain, reduce hospital time, reduce hospital charge duce hospital charge

ProcedureProcedure Endoscopic stentingEndoscopic stenting Percutaneous stentPercutaneous stent Gastrojejunostomy under laparoscopyGastrojejunostomy under laparoscopy

ChemotherapyChemotherapy

Gene TherapyGene Therapy

Periampullary Cancer Periampullary Cancer

Lower part of CBD, ampulla, papilaLower part of CBD, ampulla, papila High frequency of intestinal bleeding High frequency of intestinal bleeding

Fluctuation of jaundiceFluctuation of jaundice

ERCP are the mainstays in differentiationERCP are the mainstays in differentiation

Result is much betterResult is much better

Endocrine tumor in Endocrine tumor in pancreaspancreas

B cellB cell ，， insulininsulin ，， insulinomainsulinoma G cellG cell ，， gastringastrin ，， gastrinomagastrinoma D1 cellD1 cell ，， vasoactive intestinal peptide(VIP) vasoactive intestinal peptide(VIP)

VIPomaVIPoma A cellA cell ，， glucagonglucagon ，， glucagonomaglucagonoma D cellD cell ，， somatostatinsomatostatin ， ， somatostatinomasomatostatinoma

InsulinomaInsulinoma

Most common endocrinal Most common endocrinal tumor in pancreas , 75%tumor in pancreas , 75%

Acute attackAcute attack Long disease development Long disease development

Typical Whipple Triad

Hypoglycemia symptom after fasting or Hypoglycemia symptom after fasting or

workwork

glucose <2.8mmol/Lglucose <2.8mmol/L

Symptom relieves after administration of Symptom relieves after administration of

glucose by oral or veinglucose by oral or vein

Clinical ManifestationClinical Manifestation

Sympathetic symptomSympathetic symptom

Pale, sweat, quick HBPale, sweat, quick HB

Psychiatric symptomPsychiatric symptom

Faintness , dullness, comaFaintness , dullness, coma

Degenerative change of brain Degenerative change of brain

Confusion, disorder behavior, low intelligenceConfusion, disorder behavior, low intelligence

Hypoglycemia SymptomHypoglycemia Symptom

Laboratory test Laboratory test

Fasting blood sugar(FBS)Fasting blood sugar(FBS) Immunoreactive insulin (IRIImmunoreactive insulin (IRI ） ） > 25> 25

U/mlU/ml Oral glucose tolerance test (OGTT)Oral glucose tolerance test (OGTT) Insulin release testInsulin release test （（ IRI/GIRI/G ）） > 0.3> 0.3

image finding image finding

BUSBUS CTCT Selective angiography, Selective angiography, Intraoperative ultrasonographyIntraoperative ultrasonography （ （ IOUIOU

SS ）） Sensitivity nearly Sensitivity nearly 100100 ％％

LaparotomyLaparotomy

MRI

CT

CT

Treatment of insulinoTreatment of insulinomama

Resection after determined diagnosisResection after determined diagnosis

Glucose surveillance in operationGlucose surveillance in operation

Multiple lociMultiple loci

GastrinomaGastrinoma Zollinger-Ellison SyndromeZollinger-Ellison Syndrome

Triangle in pylorus, duodenum and pancreTriangle in pylorus, duodenum and pancre

atic headatic head

UlcerUlcer

TreatmentTreatment Resection of tumorResection of tumor

Total gastrectomyTotal gastrectomy

THANKTHANKSS ！！