Detailed Seminar on Carcinoma Pancreas with -
Anatomy, Epidemiology, Enteropathogenesis, Pathology, Staging , Diagnostic workup and different modalities of Treatment
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Carcinoma Pancreas.pptx
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11. Ant. Surface- First part of duodenum,
Gastroduodenal A., Transverse colon, Jejunum.
Post. Surface- IVC , Renal vein, Rt. Crus of diaphragm & Bile
duct.
22. • Neck and head :-into nodes along
pancreaticoduodenal, superior mesenteric
and hepatic arteries, & some also drain to
pre-aortic nodes & coeliac axis nodes.
• Tail and body:- into pancreaticosplenic
nodes, although some drain directly to pre-
aortic nodes.
23.
24. *Role of para-aortic lymph node sampling in pancreatic cancer surgery.
Yusuke Kazami, Hiromichi Ito, Yoshihiro Ono, Takafumi Sato, Yosuke Inoue, and Yu Takahashi
Journal of Clinical Oncology 2020 38:4_suppl, 715-71
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10.25259/IJMS_92_2020.
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cancer with special reference to India. Indian Journal of Medical Sciences. 73. 1-11.
10.25259/IJMS_92_2020.
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104. LN greater than 1 cm in
short axis or
morphologically abnormal
(e.g., are rounded, are
hypodense/heterogeneous/
necrotic, have irregular m
argins).
105.
106.
107.
108.
109.
110.
111. CT Slide showing case of Resectable CA Pancreas with no contact to SMA –
https://pubs.rsna.org/cms/10.1148/radiol.2019190422/asset/images/medium/radiol.
2019190422.va.gif
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135. *Tomlinson JS, et al. Accuracy of staging node-negative pancreas cancer: a potential quality
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136. *Diener MK, et al. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy
(classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev
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137. Pylorus preserving pancreatico-duodenectomy
Facilitate controlled gastric emptying,
reduce intestinal transit time and
enhance intestinal absorption
Not indicated in patient with
Bulky tumors in pancreatic head,
Neoplasm involving first part of duodenum
lesion associated with grossly positive pyloric
or peripyloric LNs.
138. *Kooby DA, Chu CK. Laparoscopic management of pancreatic malignancies. Surg Clin North Am 2010;90(2):427–
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140.
141.
142.
143. • Provides immediate therapy for subclinical metastasis
• initiation of local and systemic therapy shortly after diagnosis
rather than weeks following surgery
144. *Cameron JL, et al. Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer.
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145.
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148. *Stessin AM, Meyer JE, Sherr DL. Neoadjuvant radiation is associated with improved survival in
patients with resectable pancreatic cancer: an analysis of data from the surveillance,
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1133.
149. *Stessin AM, Meyer JE, Sherr DL. Neoadjuvant radiation is associated with improved survival in
patients with resectable pancreatic cancer: an analysis of data from the surveillance,
epidemiology, and end results (SEER) registry. Int J Radiat Oncol Biol Phys 2008;72(4):1128–
1133.
150.
151.
152.
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154. *Neuhaus P, et al. CONKO-001: final results of the randomized, prospective, multicenter phase III trial of adjuvant chemotherapy with
gemcitabine versus observation in patients with resected pancreatic cancer (PC). J Clin Oncol 2008;26:(abstr LBA4504)
155. *Neoptolemos JP, et al. Adjuvant chemotherapy with fluorouracil plus folinic acid vs gemcitabine following
pancreatic cancer resection: a randomized controlled trial. JAMA 2010;304(10):1073–1081.
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pancreatic cancer resection: a randomized controlled trial. JAMA 2010;304(10):1073–1081.
157. *Neoptolemos JP, Palmer DH, Ghaneh P, et al. Comparison of adjuvant gemcitabine and capecitabine with
gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label,
randomised, phase 3 trial. Lancet 2017;389:1011–1024.
158. *Neoptolemos JP, Palmer DH, Ghaneh P, et al. Comparison of adjuvant gemcitabine and capecitabine with
gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label,
randomised, phase 3 trial. Lancet 2017;389:1011–1024.
159. *Neoptolemos JP, Palmer DH, Ghaneh P, et al. Comparison of adjuvant gemcitabine and capecitabine with
gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label,
randomised, phase 3 trial. Lancet 2017;389:1011–1024.
160.
161.
162.
163.
164.
165.
166.
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
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resectable and borderline resectable pancreatic cancer: Results of the Dutch Randomized Phase III PREOPANC
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178. *Le Scodan R, Mornex F, Girard N, et al. Preoperative chemoradiation in potentially resectable pancreatic adenocarcinoma:
Feasibility, treatment effect evaluation and prognostic factors, analysis of the SFRO-FFCD 9704 trial and literature review. Ann
Oncol 2009;20:1387-1396.
179.
180.
181. *Huguet F, Girard N, Guerche CS, et al. Chemoradiotherapy in the management of locally advanced pancreatic carcinoma: A
qualitative systematic review. J Clin Oncol 2009;27:2269-2277
182.
183.
184. Head of
pancreas
Body or tail
Superior
border
T10/T11 level (to
include celiac nodes)
Slightly higher
Inferior border L3/L4 level (depend
on pre-operative
imaging studies)
Same
Right border 2 cm right of pre-op
duodenum
same
Left border 2 cm from left
border of vertebral
body
More towards left
side to include
splenic hilum
AP-PA field borders :
185. Head of pancreas Body or tail
Superior border Same as AP-PA Same as AP-PA
Inferior border Same as AP-PA Same as AP-PA
Anterior margin 1.5-2 cm beyond gross
disease.
same
Posterior margin 1.5-2 cm of the anterior
portion of the vertebral
body (in the field) to
allow the margin on the
para-aortic nodes.
same
186.
187. Parameters Head of pancreas Body or tail of
pancreas
Treatment volumes Pancreatico-duodenal,
suprapancreatic, celiac and
porta hepatis LN
+ entire duodenum +
2-3 cm beyond the gross
disease
Pancreatico-duodenal
and porta hepatis
nodes, lateral
suprapancreatic nodes
and nodes of splenic
hilum (± duodenal
loops) + 2-3 cm
margin beyond the
gross disease)
188.
189. The post operative CTV should include:
Based on location of initial tumor from pre-operative imaging and pathology reports
Anastomoses - Pancreaticojejunostomy(PJ) , choledochal or hepaticojunostomy
Abdominal nodal regions – Peripancreatic , Celiac , Superior mesenteric , Porta hepatis , Para-aortic
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isolated local recurrence of pancreatic cancer after multimodality therapy: Experience from two institutions. Journal of Gastrointestinal
Oncology 4(4): 343–351
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205.
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217.
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cancer. N Engl J Med 2004;350(12):1200–1210.
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cancer. N Engl J Med 2004;350(12):1200–1210.
222.
223.
224.
225.
226.
227.
228.
229. * Moore MJ, et al. Erlotinib plus gemcitabine compared with gemcitabine alone in patients with advanced pancreatic
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Hinweis der Redaktion
It may finish at the base of the splenorenal ligament or extend upto splenic hilum, in which case it is prone to injury at splenectomy during ligation of the splenic vessels.
Main pancreatic duct (of Wirsung):- runs within substance of gland from left to right , receiving lobular ducts join it almost at right angles to its axis, forming a ‘herringbone pattern'.
As it reaches neck of the gland it turns inf. and post. towards the bile duct, which lies on its right side.
The two ducts enter the wall of the descending part of the duodenum obliquely and unite in a short dilated hepatopancreatic ampulla.
The accessory pancreatic duct (of Santorini) :- drains the upper part of the ant. portion of head of pancreas
It is formed within the substance of the head from several lobular ducts and ascends ant. to the main duct.
Accessory duct opens onto a small rounded minor duodenal papilla, which lies about 2cm anterosuperior to the major papilla
The sup. pancreaticoduodenal artery – It is usually double.
The ant. artery is a terminal branch of gastroduodenal A. and descends in ant. groove b/w D2 and head of pancreas. It supplies branches to the head of pancreas and anastomoses with the ant. division of inferior pancreaticoduodenal A.
The post. artery is a separate branch of the gastroduodenal A. arising at upper border of D1 .It anastomoses with the post division of inferior pancreaticoduodenal A. It supplies branches to head of pancreas , D1 & D2
Inf. pancreaticoduodenal A.- It arises from SMA near superior border D3 . It divides into ant. and post. branches.
The ant. branch anastomose with ant. superior pancreaticoduodenal A. Post.branch runs posteriorly and anastomoses with posterior superior pancreaticoduodenal A.
Both branches supply the pancreatic head, its uncinate process and D2 , D3.
Pancreatic branch of splenic a
Octreotide - is an octapeptide that mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of growth hormone
Carbohydrate antigen
A Carbohydrate antigen 19-9
Main portal vein
The modified Appleby procedure, a technique that removes two-thirds of the pancreas, the spleen, and the celiac axis,
Flow chart summarises the management
for patients with resectable tumors should ideally be conducted in a clinical trial. Generally, use similar paradigms as for locally advanced
unresectable disease.
Standard margin expansions for unresectable cases include the gross tumor and any pathologic lymph nodes (GTV) plus a 0.5–1.5
cm margin to target microscopic extension (CTV) and an additional 0.5–2 cm volume to account for tumor/breathing motion and patient
set-up errors (PTV).
If the GTV contour extends to or below the bottom of L2 then contour the aorta towards the the bottom of L2 then contour the aorta towards the bottom of the L3 vertebral body as needed to cover the region of the preoperative tumor location
Expansion 1
1.0 cm expansion on PV, PJ, CA, and SMA
Expansion 2
2.5 to 3.0 cm to the right,1.0 cm to the left, 2.0 to 2.5 cm anteriorly, 0.2 cm posteriorly on Aorta
CTV: Boolean addition (merging) of Expansion 1 and 2 (Confirm that CTV encompasses tumor bed and contoured clips)
PTV : 0.5 cm expansion on CTV
