Download Pancreatic Cancer - Sheba Hungary Student

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Document related concepts
no text concepts found
Transcript
Pancreatic Cancer
Incidence and Epidemiology
• 25,000-30,000 diagnosed annually in the
US
• or fifth leading cause of cancer-related
death
• Prevalent in men and African Americans
• 80% of cases occur between the ages 60
and 80
Anatomy
Risk Factors
•
•
•
•
•
Family History of Pancreatic Cancer
Chronic or Hereditary Pancreatitis
Smoking
Exposure to occupational carcinogens
Relation to DM is controversial
Pathology
• Ductal adenocarcinoma account for 80%
to 90% of all pancreatic neoplasms
• 70% of ductal cancers arise in the
pancreatic head or uncinate process
• At diagnosis - both nodal and distant
metastases are frequently present
Pathology
• Areas of vascular and
lymphatic invasion
within and around the
tumor are commonly
seen
• perineural growth of
the tumor is highly
characteristic and
causes upper
abdominal and back
pain
Different Variants of
Adenocarcinoma
• Mucinous Noncystic Carcinoma (Colloid
Carcinoma)
• Signet Ring Cell Carcinoma
• Adenosquamous Carcinoma
• Anaplastic Carcinoma
• Giant Cell Carcinoma
• Sarcomatoid Carcinoma
Molecular Biology
•
•
•
•
•
•
K-Ras
Early events in tumorogenesis
EGFR, HER2/3/4
p53
Late events in tumorogenesis
BRCA2
Less common : Retinoblastoma, APC
…
Hereditary Pancreatic Cancer
Syndromes
•
•
•
•
•
HNPCC
BRCA2 mutation carriers
Peutz-Jeghers Syndrome
AT
Familial Atypical Multiple Mole Melanoma
(FAMMM)
Ataxia Telangectasia
?
Peutz Jegher Syndrome
jejunojejunal proximal
intussusceptions
Symptoms and Signs
• insidious tumors that can be present for
long periods and grow extensively before
they produce symptoms.
• The symptoms, once they develop, are
determined by the location of the tumor in
the pancreas
Sings and Symptoms – Pancreatic
Head Cancer
•
•
•
•
•
•
Weight Loss (92%)
Pain (72%)
Jaundice (82%)
Anorexia (64%)
Dark urine (63%)
Light Stool (625)
Sings and Symptoms – Pancreatic
Body or Tail Cancer
•
•
•
•
•
•
Weight Loss (100%)
Pain (87%)
Weakness (43%)
Nausea (45%)
Vomiting (37%)
Anorexia (33%)
Physical Examination
• Dependent on location and size of the
pancreatic tumor
• Metastatic subumbilical noudle (“Sister Mary
Joseph node”)
• left supraclavicular lymphadenopathy (“Virchow's
node”)
• pelvic peritoneal (“Blumer's shelf”) deposits
• Portal HTN, Ascits, Caput Medusae, GE Varices
Sister Mary Joseph’s Noudle
Courvoisier’s Sign
• Painless Jaundice
• Distended
Gallbladder
Lab Tests
•
•
•
•
Head Lesions
Bilirubin
ALP
Tumor markers : CEA, CA19-9
• Normal Serum levels on early disease
• Increased Serum levels on Cholangitis,
Obstructive Jaundice
Imaging Studies
• For most patients, the initial imaging study
is a transcutaneous US.
• Usually followed by helical contrastenhanced CT
• hypodense mass with poorly demarcated edges. It
may have a more hypodense center, indicating
central necrosis or cystic change
• Sensitivity up to 95% for diameter >2 cm
Imaging Studies
• MRI - sensitivity and specificity of MRI
appear to equal those of CT
• PET - diagnosing small pancreatic tumors
that escaped CT or MRI detection
• ERCP - helpful in evaluating patients with
obstructive jaundice without a detectable
mass on CT or MRI
Double Duct Sign
• superimposable bile duct
and pancreatic duct
strictures (i.e., the doubleduct sign) on ERCP is highly
suggestive of a pancreatic
head
• DD: Chronic pancreatitis,
Autoimmune pancreatitis
Role of Biopsy
• required before chemoradiation therapy of
unrsectable tumor or neoadjuvant
treatment of resectable tumors
• Transcutaneous: CT/US Guided
• Transduodenal : EUS
• Drawbacks of Biopsy:
• May yield FN Results, doesn’t affect management
• Theoretical possibility of peritoneal spread
TNM Staging
• T0 – Tis/PAN-IN3
• T1/2 – Below/Above 2 cm in diameter
• T3/4 – Local extension beyond pancreas
• T3 lesions are considered to be potentially
resectable because they do not involve the celiac
axis or superior mesenteric artery.
• T4 lesions are considered to be unresectable
because they involve the critical peripancreatic
arteries
TNM STaging
•
•
•
•
•
•
•
Stage 0 Tis N0 M0
Stage 1A T1 N0 M0
Stage 1B T2 N0 M0
Stage 2A T3 N0 M0
Stage 2B T1/T2/T3 N1 M0
Stage 3 T4 Nx M0
4Stage Tx Nx M1
Staging
• Stage I and II cancers are amenable to
resection
• Poor prognostic signs
•
•
•
•
aneuploidy
large tumor size (T2)
positive regional nodes (N1)
incomplete resection at the pancreatic or
retroperitoneal margin
Staging
• Stages III and IV cancers are considered
to be unresectable
• Stage III due to vascular invasion
• Stage IV due to distant metastases
• Mean survival
• Stage III – 8-12 mo.
• Stage IV – 3-6 mo.
Imaging for Staging
• High-resolution helical CT, with phased
imaging. Signs of unresectibility
• Circumferential encasement, invasion, or occlusion
of the portal vein, SMV, or SMA
• extension beyond the pancreatic capsule and into
the retroperitoneum
• involvement of neural or nodal structures
• extension of the tumor along the hepatoduodenal
ligament
Role of Laparoscopy in Staging
• Patients believed to have stage I or II
disease may have unrecognized small
metastases to peritoneal surfaces (e.g.,
diaphragm, liver) and that those
metastases can be laparoscopically
detected, thus preventing a needless
laparotomy
Resectional Surgery for Pancreatic Head
and Uncinate Process Tumors
• Tumors of the head, neck, and uncinate
process of the pancreas account for about
70% of pancreatic tumors
• Resected by pancreaticoduodenectomy
• Pylorus sparing – faster and easier, same
morbidity and mortality but greater chance for
delayed gastric emptying.
Pancreaticoduodenectomy
(Whipple’s procedure)
• preliminary search for metastases or other reasons to abort
resection
• The gallbladder is usually removed
• the common bile duct is divided above the duodenum
• The proximal GI tract is divided at the level of the gastric antrum
(standard Whipple) or 1st part of the duodenum (pylorus-preserving)
• The proximal jejunum is divided, and the neck of the pancreas is
transected
• uncinate process of the pancreas is resected from the
retroperitoneum along the lateral surface of the superior mesenteric
artery
Pancreaticoduodenectomy
(Whipple’s procedure)
• pancreaticojejunostomy (as an
end-to-end or end-to-side)
• end-to-side
hepaticojejunostomy
• gastrojejunostomy (standard
Whipple) or
duodenojejunostomy (pyloruspreserving Whipple)
Comlications of
Pacreatoduodenectomy
• When performed by experienced surgeons
mortality rate is 2% to 4%
• Anastamotic Leaks
• Intra abdominal abcesses
• Delayed gastric emtying
• pancreatic malabsorption and steatorrhea
Results of Pancreaticoduodenectomy
• 10-15% 5-ys. Survival, usually don’t
survive additional 5 ys.
• Tumor free margins – 26% 5-ys. survival
• Tumor positive margins – 8% 5-ys. survival
• Other prognostic factors: tumor diameter, diploid or
aneuploid DNA content, and lymph node status
Resectional Surgery for Pancreatic
Body and Tail Tumors
• Only 10% deemed resectable at diagnosis
• Resection involves a distal
pancreatectomy +/- splenectomy
• Complications:
• Subphrenic Abcess (5-10%)
• Pancreatic duct leak (20%)
• Outcome – 8-14% 5-ys. survival
Palliative Nonsurgical Treatment of
Pancreatic Cancer
• Jaundice – Drainage either percutanously
endoscopically, placement of a metal or plastic stent
• Gastric Outlet obstruction – direct extension of the tumor
into the duoudenum. Placement of a stent
endoscopically into the duodenum.
• Pain – Invasion into peripancreatic nerve plexuses.
Analgetics, Narcotics, Percutaneous CT/US guided
Celiac Plexus Block
Palliative Surgical Management of
Pancreatic Cancer
• Jaundice - cholecystojejunostomy or a
choledochojejunostomy
• Gastric Outlet Obstruction - can be managed by creation
of a side-to-side gastrojejunostomy
• pain - can be achieved, intraoperatively, by injecting
alcohol into the celiac plexus, and some surgeons
routinely perform operative celiac plexus block at the
time of surgical palliation
Chemoradiation Therapy
• best results have been achieved using
radiation therapy combined with either 5fluorouracil or gemcitabine
• Patients undergoing resection may also
benefit from adjuvant chemoradiation
therapy