PANCREATIC CARCINOMA

Dr.B.Selvaraj MS;Mch;FICSProfessor of surgery

Melaka Manipal Medical CollegeMelaka 75150 Malaysia

OBSTRUCTIVE JAUNDICE

Pancreas- Anatomy

Pancreas- Blood supply

Classical Clinical

Vignette• 72 yrs old man presents with jaundice for

7days with dull abdominal discomfort for 2 months. He gives H/O loss of appetite and loss of weight.

• His stools have become lighter in color and his urine is much darker than before

• He has a 50+ pack-year smoking history before quitting last year

• He was recently diagnosed with type 2 diabetes, but has no other medical problems

Classical Clinical

Vignette• O/E: he has a yellow hue to his eyes and

tongue, along with scratch marks on his skin.• A non-tender globular mass is palpated in the

right upper quadrant (RUQ) of the abdomen • Labs: Laboratory testing reveals total and

direct bilirubin of 18 mg/dL (normal 0.2–1.3 mg/dL) and 17.2 mg/dL (<0.3 mg/dL), respectively.

• Alkaline phosphatase (ALP) elevated at 215 μ/L (33–131 μ/L). AST & ALT mildly elevated

• 3rd most common GIT cancer.• 4th most common cause of cancer

death• Death to incidence ratio is one. ( lowest among all types of cancer).

why???• Male:Female ratio 2:1• Peak age 65 to 75 yrs• Common in black americans

Introduction

Risk factors

• Cigarette smoking.• Increased age.• Chronic pancreatitis.• Family H/O Pancreatic Cancer in more

than 2 first degree relatives• Increased saturated fat intake.• Exposure to non chlorinated solvents

Genetic Risk factors

• Chronic familial relapsing pancreatitis.• Familial breast cancer ( BRCA2).• Peutz –Jeghers syndrome.• HNPCC (Hereditary non polyposis

colorectal cancer)• Gardener syndrome.• Familial atypical mole and melanoma

syndrome.

Genetic progression

Pathology• Site :55% head of pancreas;25% body 15% tail; 5% periampulary • Macroscopic : growth is hard & infiltrating• Histology :90% ductal adeno ca; 9% cystic neoplasms 1% endocrine neoplasms• Spread :Lymphatics to peritoneum & regional

nodes Blood to liver & lung Perineural spread Back pain

Clinical features

• Head&Periampulary : Painless progressive jaundice with palpable GB- “Courvoisier’s Law”; Vomiting due to duodenal block

Tea color urine, clay color stool & pruritus• Body : back pain,anorexia,weight loss &

steatorrhea• Tail : often presents with metastases,malignant

ascites or unexplained anemia

Investigations

• Lab : Elevated total & direct bilirubin High Alk Phosphatase& GGT Tumor marker CA19-9 >200U/ml• USG Abd : can detect huge tumors can’t pickup small mass• MDCT : Triple phase CT abdomen: with arterial

& portal venous phase is sensitive to pickup even small hypodense lesions

Investigations

• ERCP & MRCP : “Dual duct sign” Therapeutic ERCP for palliative stent in

CBD & Duodenum• Endoscopic Ultrasound:(EUS) Excellent for staging the tumor EUS guided pancreatic biopsy

CT Abdomen

ERCP “Dual Duct Sign”

Periampulary Mass &EUS

Staging

Stage1 :Tumor is limited to pancreas with no nodes or metastases

Stage2 :Tumor extends into bile duct, peripancreatic tissues or duodenum. No nodes or metastases

Stage3 :as stage 2 + positive nodes or celiac or SMA involvement

Staging

Stage4a : Tumor extends to stomach,colon,spleen or major vessels with any nodal status and no distant metastases

Stage4b : Distant metastases with any nodal status or tumor size

Staging & Prognosis

Treatment • Rescectable tumors• Borderline resectability• Unresectable tumors

Resectable tumors

• Normal fat planes between tumor and SMA, SMV

• Absence of extrapancreatic disease• Patent SMPV confluence • No direct extension to celiac axis or

SMA

Borderline tumors

• Short segment occlusion of SMPV confluence with an adequate vessel for grafting

• Short segment (< 1 cm ) abutment of the common or proper hepatic artery or SMA on high quality CT

Unresectable tumors

• Extrapancreatic disease- distant metastases

• Encasement of coelic axis or SMA ( anything more than short abutment)

Treatment Algorithm

Whipple’s Operation

Complications

• Delayed gastric emptying• Pancreatic fistula• Intra-abdominal abscess• Operative site hge• GI Hemorrhage

Palliative Surgery

• Biliary obstruction: Biliary enteric bypass Endoscopic biliary stent

placement Radiographic transhepatic

stent placement

Palliative Surgery

• Gastric outlet obstruction:

Gastroenteric bypass Endoscopically placed

duodenal stent

Palliative Bypass

Adjuvant therapy

• 85% local recurrence .→ RT• 70% liver metastasis.→CT• 5 FU is the only active agent.• Gemcitabine.• 5 FU + Gemcitabine

Mindmap

Treatment Algorithm