A review of methods of diagnosis and treatment of adenocarcinoma of the pancreas, with a focus on tumors of the head of the pancreas.

1. Gian Luca Grazi
Hepato-Biliary-Pancreatic Surgery
National Cancer Institute Regina Elena
Rome
Pancreatic adenocarcinoma:
diagnosis and treatment
(20 minutes)

2. Pancreatic adenocarcinoma: diagnosis and treatment
https://ecis.jrc.ec.europa.eu/

3. Pancreatic adenocarcinoma: diagnosis and treatment
https://ecis.jrc.ec.europa.eu/

4. Pancreatic adenocarcinoma: diagnosis and treatment
15%
10%
Tumori periampollari
60-80%

5. Pancreatic adenocarcinoma: diagnosis and treatment
Common presenting symptoms of pancreatic cancers
•Jaundice
(for tumours of the head),
•abdominal pain,
•weight loss,
•steatorrhoea, and
•new-onset diabetes.
Tumours can grow locally
into the duodenum (proximal
for tumour of the head and
distal for tumour of the body
and tail) and result in an
upper gastroduodenal
obstruction.
Ducreux M, Ann Oncol 2015: 26 (Supplement 5): v56–v68

6. Pancreatic adenocarcinoma: diagnosis and treatment
What is needed in the radiological diagnosis of
pancreatic cancer ?
Ducreux M, Ann Oncol 2015: 26 (Supplement 5): v56–v68
 Tumour size and
 Precise burden,
 Arterial and Venous local involvement
 Presence of distant metastases (liver!)

7. Pancreatic adenocarcinoma: diagnosis and treatment
Ducreux M, Ann Oncol 2015: 26 (Supplement 5): v56–v68

8. Pancreatic adenocarcinoma: diagnosis and treatment
https://www.chirurgiadelfegato.it/pancreas/tumore-pancreas/tumore-alla-testa-del-pancreas/
Superior Mesenteric Artery
Pancreatic Cancer
Duodenum

9. Pancreatic adenocarcinoma: diagnosis and treatment
Al-Hawary MM, Gastroenterology 2014; 146: 291-304

10. Pancreatic adenocarcinoma: diagnosis and treatment
Arterial Tumor Contact
Less than or equal
to 180°tumor
contact without
deformity.
More than 180°
tumor contact
without deformity.
Tumor contact with
deformity (arrow).
Al-Hawary MM, Gastroenterology 2014; 146: 291-304

11. Pancreatic adenocarcinoma: diagnosis and treatment
Al-Hawary MM, Gastroenterology 2014; 146: 291-304
Venous Tumor Contact
Less than or equal
to 180°tumor
contact without
deformity.
Less than or equal
to 180°tumor
contact with
deformity (arrows).
More than 180°
tumor contact
without deformity.
Tear drop
deformity (arrows).

12. Pancreatic adenocarcinoma: diagnosis and treatment
Resectable
R
Borderline Resectable
BR
Unresectable
UR
Venous Involvement alone
BR-PV
Arterial Involvement
BR-A
Locally advanced
LA
Metastatic
M
SMV/PV No contact or
unilateral narrowing
Tumor contact 180° or greater
or bilateral
narrowing/occlusion, not
exceeding the inferior border
of the duodenum
Bilateral
narrowing/occlusion,
exceeding the inferior
border of the duodenum
SMA, CA No tumor contact No tumor contact/invasion Tumor contact < 180°
without deformity/stenosis
Tumor contact/invasion
of 180° or more degree
CHA No tumor contact No tumor contact/invasion Tumor contact without
showing tumor contact of
the PHA and/or CA
Tumor/contact/invasion
of the PHA and/or CA
AO Tumor contact or
invasion
M Distant
metastases
Isaji S, Pancreat 2018, 18: 2-11
International Consensus of Classification of Borderline Resectable Pancreatic Tumor
SMV: superior mesenteric vein, PV: portal vein, SMA: superior mesenteric artery, CA: celiac artery,
CHA: common hepatic artery, PHA: proper hepatic artery

13. Pancreatic adenocarcinoma: diagnosis and treatment

14. Pancreatic adenocarcinoma: diagnosis and treatment
We still do not know how many patients progressed under
neoadjuvant chemotheraphy while they were operable or
borderline operable at the beginning.

15. Pancreatic adenocarcinoma: diagnosis and treatment
• An increase in serum levels is seen in almost 80% of the patients with advanced disease.
• In patients not harbouring a functional Lewis enzyme (Lea-b- genotype: 7%–10% of the population),
levels of CA 19-9 are typically undetectable or below 1.0 U/ml.
• The level of CA 19-9 is correlated to the level of bilirubin and any cause of cholestasis is able to induce
false-positive results.
• CA 19-9 has a significant value as a prognostic factor and can be used as a marker to measure disease
burden and potentially guide treatment decisions.
• A preoperative serum CA 19-9 level ≥500 UI/ml clearly indicates a worse prognosis after surgery.
CA 19-9 is not useful for the primary diagnosis of pancreatic cancer.
Ducreux M, Ann Oncol 2015: 26 (Supplement 5): v56–v68

16. Pancreatic adenocarcinoma: diagnosis and treatment
Should we drain the jaundiced patient ?
Jaundice is not an emergency situation!!!

17. Pancreatic adenocarcinoma: diagnosis and treatment
Outcome No PreOp Biliary
Drainage
Plastic Stent Metal stent Percutaneous
catheter
Any Post-operative
complication
80 (79%) 46 (50%) 47 (50%) 27 (22%)
Intraabdominal
infection
62 (64%) 34 (39%) 53 (57%) 52 (41%)
Post-operative
hemorrage
42 (40%) 49 (51%) 52 (58%) 58 (51%)
Wound infection 96 (88%) 19 (22%) 54 (51%) 31 (399%)
The probability that an approach is better than other approaches for a given clinical outcome (i.e. P-scores).
The best approach is highlighted

18. Pancreatic adenocarcinoma: diagnosis and treatment

19. Pancreatic adenocarcinoma: diagnosis and treatment
https://www.chirurgiadelfegato.it/pancreas/tumore-pancreas/tumore-alla-testa-del-pancreas/dcp/

20. Pancreatic adenocarcinoma: diagnosis and treatment

21. Pancreatic adenocarcinoma: diagnosis and treatment
Patients aged 80 years and older have approximately double the risk of
30-day postoperative mortality and 50% increased rate of complications
following PD.
Careful patient selection is required when offering surgery in this age
group.

22. Pancreatic adenocarcinoma: diagnosis and treatment

23. Pancreatic adenocarcinoma: diagnosis and treatment
Tan E, Int J Surg 2019; 72: 59-68

24. Pancreatic adenocarcinoma: diagnosis and treatment
Tan E, Int J Surg 2019; 72: 59-68

25. Pancreatic adenocarcinoma: diagnosis and treatment
Tan E, Int J Surg 2019; 72: 59-68

26. Pancreatic adenocarcinoma: diagnosis and treatment
Pancreatic resection of pancreatic adenocarcinoma can
be performed safely on elderly patients with acceptable
risks in tertiary centres by experienced specialist
hepatobiliary surgeons.
Age alone should not be the only determinant for the
selection of patients for surgical treatment.
A better understanding of the barriers to the provision of
adjuvant chemotherapy and aggressive surgery (to
achieve clear surgical margins) is needed.
Tan E, Int J Surg 2019; 72: 59-68

27. Pancreatic adenocarcinoma: diagnosis and treatment
Geriatric assessment included the following specific testing, 4 (of
5) components of Fried’s frailty:
1) self-reported unintentional weight loss of 10 lb or more in
the previous 12 months;
2) height-adjusted slow gait speed;
3) muscular weakness as measured by a gender-adjusted grip
strength pressure on a hand dynamometer (lowest 20%); and
4) self-reported patient exhaustion measured by 2 survey
questions.

28. Pancreatic adenocarcinoma: diagnosis and treatment

29. Pancreatic adenocarcinoma: diagnosis and treatment

30. Pancreatic adenocarcinoma: diagnosis and treatment
Pawlik TM, Ann Surg Oncol 2008, 15: 2081-2088

31. Pancreatic adenocarcinoma: diagnosis and treatment
TAKE HOME MESSAGE

32. Pancreatic adenocarcinoma: diagnosis and treatment
 Avoid unnecessary radiologic tests
(a well done CT could be enough)
 Early refer the patients with a suspected pancreatic cancer
to an HepatoPancreatoBiliary Unit with an established HPB
surgical unit
 Do not drain the jaundiced patients before having obtained
the opinion on surgical resecatibility

33. Pancreatic adenocarcinoma: diagnosis and treatment
Gian Luca Grazi
Hepato Biliary Pancreatic Surgery
National Cancer Institute “Regina Elena”, Rome, Italy
gianluca.grazi@ifo.gov.it
www.chirurgiadelfegato.it

34. Pancreatic adenocarcinoma: diagnosis and treatment