Download MBBS General Surgery PPT 9 Pancreatic Carcinoma Lecture Notes

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Pancreatic

carcinoma

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Clinical vignette

72 years old man presented with jaundice for 7 days with

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dul abdominal discomfort for 2 months. He gives H/O loss

appetite and loss of weight.

He is passing clay color stools.

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

year.

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He was recently diagnosed with type 2 diabetes, but has no

other medical problem

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O/E: He has a yellow hue to his eye and tongue, along

with scratch marks on his skin

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A non-tender globular mass is palpable in right upper

outer quadrant of the abdomen

Ix : Laboratory testing reveals total and direct bilirubin

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of 18 mg/dl(normal 0.2-1.3 mg/dL) and 17.2 mg/dL

(<0.3 mg/dL), respectively.

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Alkaline Phosphatase (ALP) elevated at 215 ?/L (33-131

?/L). AST & ALT mildly elevated.

Anatomy of pancreas

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Blood supply of pancreas

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INTRODUCTION

? 3rd most common GIT cancer.

? 4th most common cause of cancer death

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? Male to female ratio 2:1

? Peak age 65 to 75 years

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? More common in African-American males

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Risk Factors

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? Cigarette smoking

? Diabetes mel itus

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? Chronic pancreatitis

? Family H/o Pancreatic cancer in more than 2 first degree

relatives

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Contd.

? Increased fat intake

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? Chronic familial relapsing pancreatitis.

? Familial breast cancer (BRCA-2)

? Peutz Jegher syndrome

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Contd.

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? HNPCC (Hereditary non polyposis colorectal cancer)

? Gardener syndrome

Pathology

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Site:- 55% head of pancreas; 25 % body; 15% tail; 5 %

periampullary

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Macroscopic : Growth is hard & infiltrating

Histology:
90% ductal adeno ca
9% cystic neoplasms

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1% endocrine neoplasms

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Spread:

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Local Spread


To adjacent structure like duodenum, portal vein

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, superior mesenteric vein, retroperitoneum.

Spread is more likely in carcinoma head of

pancreas than in periampullary carcinoma

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Perineural spread is common

Nodal Spread:

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Usual y to perihepatic nodes around the duodenum and CBD,

subpyloric, celiac nodes.

Hard dark greenish nodes are typical. Often nodal enlargement

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Distant Spread:

To Liver as multiple secondaries

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Occasional y to lungs, adrenals, brain and bone etc.

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Clinical Features

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Head & Periampul ary : Painless progressive jaundice with

palpable GB ? " Courvoisier's Law";

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Vomiting due to duodenal obstruction

Ampullary tumors mainly present with jaundice and weight loss

CA head of pancreas and neck present with weight loss and

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jaundice

Cystadenoadenoma present with pain and weight loss and mass.

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Jaundice

obstructive

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progressive

A/w pruritis ( due to deposition of bile salts in the skin which

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releases histamine).

Waxing and Waning (due to necrosis of tumor jaundice is

relieved thus being intermittent).

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Contd.

Pain in the right hypochondrium, epigastrium

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Back pain d/t involvement reteropancreatic nerves , pancreatic duct

obstruction or stasis, disruption of nerve sheath

Diarrhoea, steatorrhea, alcoholic stools, tea colored stools

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Loss of appetite and weight

Scratch marks on back

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Contd.

Silvery stools

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Loss of appetite and weight

Scratch marks on back

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Left supraclavicular lymph node.

Migratory Superficial thrombophlebitis- Trousseau's sign is due to release of platelet

aggregating factors from tumor or its necrotic material.

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Contd.

Ascitis

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Secondaries in reterovesical pouch ( blummer shelf)

Hydrohepatosis

Splenic vein thrombosis with splenomegaly

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INVESTIGATIONS

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Liver function tests: Serum bilirubin, direct component

(conjugated) is increased. Serum albumin is decreased

Prothrombin time is increased

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Ultrasound Abdomen? findings

Contd.

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Barium meal shows widened duodenal "C" loop ? pad sign
reverse 3 sign is seen in carcinoma ? periampul ary region

Spiral CT Scan ? shows portal vein infilteration, reteroperitoneal L.N and

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tumor size

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ERCP

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Endoscopic ultrasound technique

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Contd.

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MRCP

CA19-9 : - more than 37 units/ml

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Endosonography

Gastroduodenosocopy

Urine test

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Contd.

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Trucut biopsy is not advised

Diagnostic laparoscopy

CT angiogram

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PTC ? if ERCP fails if lesion is proximal

Staging

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T ? Tumor

N ? Nodal status

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M - Metastasis

Tx- Primary cannot be assesed

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Nx- - Regional node cannot be

Mx- Cannot be assesed

assesed

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T0- No evidence of tumor

N1- No nodal spread

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M0- No distant spread

Tis-carcinoma in situ

N2- Nodal spread present

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M1- Distant metastasis present

T1- limited to pancreas <2 cms

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T2-limited to pancreas >2 cms

T3- extension to duodenum or bile

duct

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T4- Extension to portal

vein,SMV,Stomach,spleen,colon,

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celiac plexus

R0- No residual tumor found after resection

R1- Microscopic residual after resection

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R2- Macroscopic residual after resection

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S. no.

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Dif erences between features of carcinoma head of pancreas & periampul ary carcinoma of

pancreas

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Carcinoma of head of

Periampul ary carcinoma

pancreas

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1

Pain and weight loss

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Early features

late features

2

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Jaundice

Persistent and progressive

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Waxing and waning

3

Occult blood in stool

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Absent

Present

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stools are silvery

4

Endoscopic examination

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Growth not visible

Growth visible

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5

Prognosis

Not good

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Good

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Pre- operative preparation

Adequate hydration

Glycogen reserve in liver wil be inadequate so preop glucose in given

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oral y or intravenously

Pts are prone to hepatorenal syndrome so. Mannitol needs to be started

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before surgery

Inj. Vit. K to given to optimize PT-INR.

ERCP stenting- maybe done in severe obstructive jaundice

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Contd.

Antibiotics

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TPN can be given pre and post operatively

Improve pulmonary function

Respiratory physiotherapy

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Criteria for resection

Tumour size less than 3 cm

Periampul ary tumors

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Growth not adherent to portal system

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In operable cases

Whipple operation
Areas removed :-

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Head and neck of pancreas

C loop of duodenum

40% of distal stomach

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Contd.

10 cm proximal jejunum

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Lower end of bile duct

Gal bladder

Peripancreatic, pericholedochal, paraduodenal, perihepatic nodes

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Anastomoses done :-

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Choledochojejunostomy

Pancreaticojejunostomy

Gastrojejunostomy

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jejunostomy

Normal Anatomy

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Resected specimen

After whipple procedure

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Other procedures

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Transverso-longermire pylorus preserving pancreaticoduodenectomy
? Duodenum is cut 2 cms distal to pylorus and then anastomoses with

jejunum

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? Fortner's regional pancreatectomy ( extended Whipple )
? Whipple procedure + removal of segment of superior mesenteric vein

and clearance of al regional lymph nodes and portal vein . Vascularity

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is maintained by vascular graft.

Contd.

Total pancreatectomy

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Distal pancreatectomy or central pancreatectomy or total

pancreatectomy for cystadenocarcinoma depending upon

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extent and size of tumor

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Inoperable cases

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For palliative obstructive jaundice , duodenal obstruction and pain

Roux-en-Y Choldechodchojejunostomy along with

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gastrojejunostomy after doing cholecystectomy

ERCP and stenting is done to drain bile

Chemotherapy

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Steatorrhea is treated with enzymes

Adjuvant therapy

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Adjuvant chemotherapy :- using gemcitabine, 5 fluorouracil, mitomycin,

vincristine, cisplatin, docetaxel oxaliplatin

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Radioactive iodine seeds I125

External Radiotherapy

Immunotherapy

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Other endocrine tumors
Insulinoma

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o Commonest endocrine tumor arising from - cel s of pancreas.

o c/f:- Abdominal discomfort, discomfort, trembling, sweating, hunger,

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diplopia, hal ucinations, weight gain, neurological deficit

o Whipple triad :-
o Attack of hypoglycemia
o Blood sugar 45 mg% during attack

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o Symptoms relived by glucose

Gastrinoma
Arising from non beta cel s (G ? cel s) of pancreas

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Associated with MEN syndrome

C/f:- Multiple ulcer, resistant ulcer, jejunal ulcer, recurrent ulcer

Investigation :- Gastrin assay , gastroscopy, Ultrasound MRI, Angiogram,

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Increased gastrin level

Treatment :- Enucleation of tumor, distal pancreatetctomy,
Pancreaticoduodenectomy, subtotal pancreatectomy, often total

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gastrectomy

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glucaginomas
Arising from alpha cel s of pancreas

Commonly in body and tail

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common in females

C/f:- necrolytic migratory erythema, Diabetes, diarrehea, stomatitis,

anaemia

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Contd.

Investigations:- MRI, CT scan, Angiogram, Increased

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serum glucagon levels

Treatment:- distal pancreatectomy

Occasional y whipple procedure

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