Carcinoma of the pancreas

1. CARCINOMA OF THE
PANCREAS
DR. LALA ROBIN, MS. GEN. SURGERY,
CMC.

2.  sixth leading cause of cancer death in the UK and 4th leading cause in US.
 incidence is 10 cases per 100 000 population per year
 Men are affected slightly more commonly than women, with a 1.3 : 1
 The risk of pancreatic cancer increases with age beyond the sixth decade; the
mean age at diagnosis is 72 years.
 ninth most common cancer diagnosis
 Overall, less than 5% of individuals will survive 5 years beyond their diagnosis

5. Pathology
 Ductal adenocarcinoma
 85% of pancreatic cancers are ductal adenocarcinomas.
 solid, scirrhous tumours, characterised by neoplastic tubular glands within a markedly
desmoplastic fibrous stroma
 infiltrate locally, typically along nerve sheaths, along lymphatics and into blood
vessels
 Liver and peritoneal metastases
 Pancreatic intraepithelial neoplasia or PanIN - precede invasive ductal
adenocarcinoma

6.  Cystic tumours of the pancreas
 Serous cystadenomas
 mucinous cystic neoplasms (MCNs)
 intraductal papillary mucinous neoplasms (IPMNs)  Main Duct and Branch Duct
IPMNs.

7. Clinical features
 History
 Jaundice
 painless
 may be associated with nausea and epigastric discomfort
 Pruritus, dark urine and pale stools with steatorrhoea
 vague discomfort, anorexia and weight loss
 unexplained attack of pancreatitis
 Back pain - retroperitoneal infiltration

8.  Examination
 Jaundice
 palpable liver
 palpable gall bladder - Courvoisier sign (choledocholithiasis was commonly
associated with a shrunken fibrotic gallbladder, whereas the slow progressive
occlusion by other causes, including tumors, was more likely to result in ectasia of
the organ)

9. Investigation and Diagnostic Workup
 Laboratory Evaluation
 CBC
 RFT
 LFT
 coagulation profile
 nutritional assessment - prealbumin and albumin levels
 tumor markers - CEA, carbohydrate antigen 19-9 (CA 19-9), and α-fetoprotein

10.  Imaging Studies
 Ultrasound Abdomen will determine if the bile duct is dilated
 contrast-enhanced CT scan
 presence of hepatic or peritoneal metastases,
 lymph node metastases distant from the pancreatic head, or
 encasement of the superior mesenteric, hepatic or coeliac artery by tumour are clear
contraindications to surgical resection
 MRI and MR angiography can provide information comparable to CT

11.  Interventions
 ERCP and biliary stenting should be carried out if there is any suggestion of
cholangitis. It relieves the jaundice and can also provide a brush cytology or
biopsy specimen to confirm the diagnosis.
 EUS is useful if CT fails to demonstrate a tumour, if tissue diagnosis is required
prior to surgery (e.g. a mass has developed on a background of chronic
pancreatitis and a distinction needs to be made between inflammation and
neoplasia)
 Transduodenal or transgastric FNA or Trucut biopsy performed under EUS
guidance avoids spillage of tumour cells into the peritoneal cavity.
 Diagnostic laparoscopy prior to an attempt at resection can spare a proportion of
patients an unnecessary laparotomy by identifying small peritoneal and liver
metastases.

12. Surgical Management
 pylorus-preserving pancreatoduodenectomy (PPPD)
 This involves removal of the duodenum and the pancreatic head, including the distal
part of the bile duct.
 Classical Whipple procedure
 This involves removal of the gastric antrum, the duodenum and the pancreatic head,
including the distal part of the bile duct.
 Total pancreatectomy - multifocal tumour
 For tumours of the body and tail, distal pancreatectomy with splenectomy is the
standard

14. ADJUVANT CHEMOTHERAPY
 5-fluorouracil (5-FU)
 Gemcitabine
 gemcitabine with capecitabin

15. Palliation of pancreatic cancer
 Relieve jaundice and treat biliary sepsis
 ● Surgical biliary bypass
 ● Stent placed at ERCP or percutaneous transhepatic cholangiography
 Improve gastric emptying
 ● Surgical gastroenterostomy
 ● Duodenal stent

16.  Pain relief
 ● Stepwise escalation of analgesia
 ● Coeliac plexus block
 ● Transthoracic splanchnicectomy
 Symptom relief and quality of life
 ● Encourage normal activities
 ● Enzyme replacement for steatorrhoea
 ● Treat diabetes
 Consider chemotherapy

17. THANK YOU