Download MBBS (Bachelor of Medicine, Bachelor of Surgery) General Surgery PPT 9 Pancreatic Carcinoma Lecture Notes
Pancreatic
carcinoma
Clinical vignette
72 years old man presented with jaundice for 7 days with
dul abdominal discomfort for 2 months. He gives H/O loss
appetite and loss of weight.
He is passing clay color stools.
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 problem
O/E: He has a yellow hue to his eye and tongue, along
with scratch marks on his skin
A non-tender globular mass is palpable in right upper
outer quadrant of the abdomen
Ix : 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 ?/L (33-131
?/L). AST & ALT mildly elevated.
Anatomy of pancreas
Blood supply of pancreas
INTRODUCTION
? 3rd most common GIT cancer.
? 4th most common cause of cancer death
? Male to female ratio 2:1
? Peak age 65 to 75 years
? More common in African-American males
Risk Factors
? Cigarette smoking
? Diabetes mel itus
? Chronic pancreatitis
? Family H/o Pancreatic cancer in more than 2 first degree
relatives
Contd.
? Increased fat intake
? Chronic familial relapsing pancreatitis.
? Familial breast cancer (BRCA-2)
? Peutz Jegher syndrome
Contd.
? HNPCC (Hereditary non polyposis colorectal cancer)
? Gardener syndrome
Pathology
Site:- 55% head of pancreas; 25 % body; 15% tail; 5 %
periampullary
Macroscopic : Growth is hard & infiltrating
Histology:
90% ductal adeno ca
9% cystic neoplasms
1% endocrine neoplasms
Spread:
Local Spread
To adjacent structure like duodenum, portal vein
, superior mesenteric vein, retroperitoneum.
Spread is more likely in carcinoma head of
pancreas than in periampullary carcinoma
Perineural spread is common
Nodal Spread:
Usual y to perihepatic nodes around the duodenum and CBD,
subpyloric, celiac nodes.
Hard dark greenish nodes are typical. Often nodal enlargement
Distant Spread:
To Liver as multiple secondaries
Occasional y to lungs, adrenals, brain and bone etc.
Clinical Features
Head & Periampul ary : Painless progressive jaundice with
palpable GB ? " Courvoisier's Law";
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
jaundice
Cystadenoadenoma present with pain and weight loss and mass.
Jaundice
obstructive
progressive
A/w pruritis ( due to deposition of bile salts in the skin which
releases histamine).
Waxing and Waning (due to necrosis of tumor jaundice is
relieved thus being intermittent).
Contd.
Pain in the right hypochondrium, epigastrium
Back pain d/t involvement reteropancreatic nerves , pancreatic duct
obstruction or stasis, disruption of nerve sheath
Diarrhoea, steatorrhea, alcoholic stools, tea colored stools
Loss of appetite and weight
Scratch marks on back
Contd.
Silvery stools
Loss of appetite and weight
Scratch marks on back
Left supraclavicular lymph node.
Migratory Superficial thrombophlebitis- Trousseau's sign is due to release of platelet
aggregating factors from tumor or its necrotic material.
Contd.
Ascitis
Secondaries in reterovesical pouch ( blummer shelf)
Hydrohepatosis
Splenic vein thrombosis with splenomegaly
INVESTIGATIONS
Liver function tests: Serum bilirubin, direct component
(conjugated) is increased. Serum albumin is decreased
Prothrombin time is increased
Ultrasound Abdomen? findings
Contd.
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
tumor size
ERCP
Endoscopic ultrasound technique
Contd.
MRCP
CA19-9 : - more than 37 units/ml
Endosonography
Gastroduodenosocopy
Urine test
Contd.
Trucut biopsy is not advised
Diagnostic laparoscopy
CT angiogram
PTC ? if ERCP fails if lesion is proximal
Staging
T ? Tumor
N ? Nodal status
M - Metastasis
Tx- Primary cannot be assesed
Nx- - Regional node cannot be
Mx- Cannot be assesed
assesed
T0- No evidence of tumor
N1- No nodal spread
M0- No distant spread
Tis-carcinoma in situ
N2- Nodal spread present
M1- Distant metastasis present
T1- limited to pancreas <2 cms
T2-limited to pancreas >2 cms
T3- extension to duodenum or bile
duct
T4- Extension to portal
vein,SMV,Stomach,spleen,colon,
celiac plexus
R0- No residual tumor found after resection
R1- Microscopic residual after resection
R2- Macroscopic residual after resection
S. no.
Dif erences between features of carcinoma head of pancreas & periampul ary carcinoma of
pancreas
Carcinoma of head of
Periampul ary carcinoma
pancreas
1
Pain and weight loss
Early features
late features
2
Jaundice
Persistent and progressive
Waxing and waning
3
Occult blood in stool
Absent
Present
stools are silvery
4
Endoscopic examination
Growth not visible
Growth visible
5
Prognosis
Not good
Good
Pre- operative preparation
Adequate hydration
Glycogen reserve in liver wil be inadequate so preop glucose in given
oral y or intravenously
Pts are prone to hepatorenal syndrome so. Mannitol needs to be started
before surgery
Inj. Vit. K to given to optimize PT-INR.
ERCP stenting- maybe done in severe obstructive jaundice
Contd.
Antibiotics
TPN can be given pre and post operatively
Improve pulmonary function
Respiratory physiotherapy
Criteria for resection
Tumour size less than 3 cm
Periampul ary tumors
Growth not adherent to portal system
In operable cases
Whipple operation
Areas removed :-
Head and neck of pancreas
C loop of duodenum
40% of distal stomach
Contd.
10 cm proximal jejunum
Lower end of bile duct
Gal bladder
Peripancreatic, pericholedochal, paraduodenal, perihepatic nodes
Anastomoses done :-
Choledochojejunostomy
Pancreaticojejunostomy
Gastrojejunostomy
jejunostomy
Normal Anatomy
Resected specimen
After whipple procedure
Other procedures
Transverso-longermire pylorus preserving pancreaticoduodenectomy
? Duodenum is cut 2 cms distal to pylorus and then anastomoses with
jejunum
? 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
is maintained by vascular graft.
Contd.
Total pancreatectomy
Distal pancreatectomy or central pancreatectomy or total
pancreatectomy for cystadenocarcinoma depending upon
extent and size of tumor
Inoperable cases
For palliative obstructive jaundice , duodenal obstruction and pain
Roux-en-Y Choldechodchojejunostomy along with
gastrojejunostomy after doing cholecystectomy
ERCP and stenting is done to drain bile
Chemotherapy
Steatorrhea is treated with enzymes
Adjuvant therapy
Adjuvant chemotherapy :- using gemcitabine, 5 fluorouracil, mitomycin,
vincristine, cisplatin, docetaxel oxaliplatin
Radioactive iodine seeds I125
External Radiotherapy
Immunotherapy
Other endocrine tumors
Insulinoma
o Commonest endocrine tumor arising from - cel s of pancreas.
o c/f:- Abdominal discomfort, discomfort, trembling, sweating, hunger,
diplopia, hal ucinations, weight gain, neurological deficit
o Whipple triad :-
o Attack of hypoglycemia
o Blood sugar 45 mg% during attack
o Symptoms relived by glucose
Gastrinoma
Arising from non beta cel s (G ? cel s) of pancreas
Associated with MEN syndrome
C/f:- Multiple ulcer, resistant ulcer, jejunal ulcer, recurrent ulcer
Investigation :- Gastrin assay , gastroscopy, Ultrasound MRI, Angiogram,
Increased gastrin level
Treatment :- Enucleation of tumor, distal pancreatetctomy,
Pancreaticoduodenectomy, subtotal pancreatectomy, often total
gastrectomy
glucaginomas
Arising from alpha cel s of pancreas
Commonly in body and tail
common in females
C/f:- necrolytic migratory erythema, Diabetes, diarrehea, stomatitis,
anaemia
Contd.
Investigations:- MRI, CT scan, Angiogram, Increased
serum glucagon levels
Treatment:- distal pancreatectomy
Occasional y whipple procedure
This post was last modified on 07 April 2022