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 lossappetite 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 noother 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 upperouter 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--- Content provided by FirstRanker.com ---
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 & infiltratingHistology:
90% ductal adeno ca
9% cystic neoplasms
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1% endocrine neoplasms--- Content provided by FirstRanker.com ---
Spread:
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Local SpreadTo 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.--- Content provided by FirstRanker.com ---
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 obstructionAmpullary 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 ductobstruction 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 signreverse 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--- Content provided by FirstRanker.com ---
ERCP
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Endoscopic ultrasound technique--- Content provided by FirstRanker.com ---
Contd.
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MRCP
CA19-9 : - more than 37 units/ml
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EndosonographyGastroduodenosocopy
Urine test
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Contd.
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Trucut biopsy is not advisedDiagnostic 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 beMx- Cannot be assesed
assesed
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T0- No evidence of tumor
N1- No nodal spread
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M0- No distant spreadTis-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 cmsT3- extension to duodenum or bile
duct
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T4- Extension to portal
vein,SMV,Stomach,spleen,colon,
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celiac plexusR0- 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 ofPeriampul ary carcinoma
pancreas
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1
Pain and weight loss
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Early featureslate features
2
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Jaundice
Persistent and progressive
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Waxing and waning3
Occult blood in stool
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Absent
Present
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stools are silvery4
Endoscopic examination
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Growth not visible
Growth visible
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5Prognosis
Not good
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Good
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Pre- operative preparationAdequate 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 surgeryInj. 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 operativelyImprove pulmonary function
Respiratory physiotherapy
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Criteria for resectionTumour size less than 3 cm
Periampul ary tumors
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Growth not adherent to portal system
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In operable casesWhipple operation
Areas removed :-
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Head and neck of pancreasC loop of duodenum
40% of distal stomach
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Contd.
10 cm proximal jejunum
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Lower end of bile ductGal bladder
Peripancreatic, pericholedochal, paraduodenal, perihepatic nodes
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Anastomoses done :-
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CholedochojejunostomyPancreaticojejunostomy
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--- Content provided by FirstRanker.com ---
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 cholecystectomyERCP 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 I125External 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 deficito Whipple triad :-
o Attack of hypoglycemia
o Blood sugar 45 mg% during attack
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o Symptoms relived by glucoseGastrinoma
Arising from non beta cel s (G ? cel s) of pancreas
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Associated with MEN syndromeC/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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glucaginomasArising from alpha cel s of pancreas
Commonly in body and tail
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common in femalesC/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 levelsTreatment:- distal pancreatectomy
Occasional y whipple procedure
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