Pancreatic Carcinoma

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Information about Pancreatic Carcinoma

Published on April 27, 2014

Author: surgical1shl


Pancreatic Carcinoma: Pancreatic Carcinoma Jibran Mohsin PGR Surgical Unit I SIMS/Services Hospital Lahore Outline: Outline Introduction Pathophysiology Etiology Epidemiology Clinical Presentation Workup Staging Treatment Prognosis Introduction: Introduction Worldwide, ranks 13 th in incidence BUT 8 th as a cause of cancer death Worst prognosis of all malignancies DISTRIBUTION Head( Periampullary ) or Neck  66-75 % Body  15-20% Tail  5-10 % Introduction: Introduction Introduction: Introduction Classification of Pancreatic Tumors Exocrine (95%)Tumors-WHO classification Benign Serous cystadenoma Mucinous cystadenoma Intraductal papillary-mucinous adenoma Mature cystic teratoma Borderline Mucinous cystic tumor with moderate dysplasia Intraductal papillary mucinous tumor with moderate dysplasia Solid pseudopapillary tumor Malignant Ductal Adenicarcinoma (75-80% of all exocrine tumor) Serous/mucinous cystadenoma Intraductal mucinous papillary tumor Introduction: Introduction Classification of Pancreatic Tumors Endocrine Tumors Primary Connective tissue cancers Lymphomas Endocrine Tumor Source Clinical Presentation Insulinoma Beta cells Whipple’s triad Gastrinoma G cells Peptic ulcer Glucagonoma Alpha cells Diabetes, Necrolytic Migratory erythema Vipoma -Pancreatic Cholera ( Verner Morrison Syndrome) W atery D iarrhea H ypokalemia A chlorhydria ( WDHA syndrome) Somatostatinoma Delta/S cells Diabetes, Steatorrhea , Gallstones Introduction: Introduction Periampullary Carcinoma Type of Carcinoma Frequency Adenocarcinoma of head of pancreas 50 % Tumor from ampulla of vater 30% Distal bile duct carcinoma 10% Duodenal carcinoma adjacent to ampulla 10% Pathophysiology: Pathophysiology Pathophysiology: Pathophysiology SPREAD Typically, metastasizes to regional lymph nodes , then to liver and less commonly to lungs Also directly invade surrounding viscera Duodenum, stomach, and colon Metastasize to any surface in abdominal cavity via peritoneal spread ( ascites- ominous prognosis) Spread to skin as painful nodules Metastasis to bone is uncommon Rare spread to brain but can produce meningeal carcinomatosis Etiology: Etiology Frequency Etiology 40 % Sporadic 30% Smoking (most common environmental risk factor) 40 pack-year 5 time high risk 20% Dietary factors (BMI > 25 in early adulthood) (High energy diet rich in fat, low fibre ) Fresh fruits and vegetables  low risk Processed red meat high risk Alcohol per se/Poultry/dairy/coffee  No risk 5-10 % Hereditary (2-3 x risk if parent or sibling has cancer) 80-95% K-ras2 85-98%CDKN2 50% p53 55% Smad4(DPC4) BRCA-2, HER-2/ neu , p16 Etiology: Etiology Diabetes DM of 5 year duration  2 fold high risk Chronic Pancreatitis 26 fold high risk Of 20 year duration  4 % cases develop Pancreatic CA Hereditary Pancreatitis Mutation in PRSS1 gene 50 fold high risk 40 % develop CA by age of 70 Etiology: Etiology ASSOCIATIONS Peutz Jegher syndrome Multiple endocrine neoplasia (MEN I) Hereditary Nonpolyposis Colonic Cancer(HNPCC)-controversial-MSH2/MLH1 gene Familial Adenomatous Polyposis(FAP)- APC gene Gardner Syndrome Familial atypical multiple mole melanoma syndrome (FAMMM)-CDKN2A gene Von Hippel-Lindau (VHL) syndrome-VHL tumor suppressor gene Ataxia telangiectasia Hereditary breast(BRCA 2> BRCA 1) and ovarian cancers Epidemiology: Epidemiology INCIDENCE Worldwide 8-12 cases per 100, 000 persons per year Epidemiology: Epidemiology RACE Highest incidence  African American males GEOGRAPHICAL High in Native Hawaiian males, men of korean , Czech, Latvian and New zealand Maori ancestry Epidemiology: Epidemiology GENDER Male > Female AGE Median age at diagnosis in whites  69 years Median age at diagnosis in blacks 65 years Mean 60-65 years Clinical Presentation: Clinical Presentation Early clinical diagnosis difficult due to nonspecific symptoms and subtle in onset Typically present as gradual onset of nonspecific symptoms such as anorexia, malaise, nausea, fatigue, and midepigastric or back pain Significant weight loss characteristic feature LOCATION CLINICAL PRESENTATION HEAD( peri ampullary ) and NECK Weight loss and Painless Obstructive jaundice BODY and TAIL Weight loss, PAIN and Mass Clinical Presentation: Clinical Presentation MIDEPIGASTRIC PAIN can be in RHC/LHC depending on location of tumor Most common presenting symptom Mild-moderate(1/3 rd cases) –severe(1/3 rd cases) Unrelenting in nature More at night Increased by food intake and lying flat Often but always radiating to midback or lower-back Indicates invasion of retroperitoneal splanchnic nerve plexus OR Pancreatic duct obstruction/stasis OR Disruption of nerve sheath Clinical Presentation: Clinical Presentation WEIGHT LOSS Cancer-associated anorexia Subclinical malabsorption from pancreatic exocrine insufficiency caused by pancreatic duct obstruction Diarrhea, Steatorrhoea Nausea and early satiety from GOO and delayed gastric emptying Clinical Presentation: Clinical Presentation (PAINLESS*) OBSTRUCTIVE JAUNDICE Most characteristic sign of CA head of pancreas Get medical attention before tumor size enlarges to cause pain Short duration, severe, progressive Intermittent if necrosis of tumor occurs preceded by pruritis -skin bile salt deposition Scratch marks Acholic /clay colored stools Tea colored/Darkening of urine _______________________________________________________________ *To distinguish it from choledcholithiasis BUT this aphorism is not accurate Clinical Presentation: Clinical Presentation OTHERS Depression More common in pancreatic cancer than other abdominal tumors 11 times increase risk of suicide especially early postoperative period Migratory thrombophlebitis Trousseau sign of malignancy OR Trousseau syndrome Seen in 10 % cases Due to release of PAF(Platelet aggregating factors) from tumor or its necrotic material Trousseau himself died of CA pancreas who had migratory thrombophlebitis Trousseau syndrome (Migratory thrombophlebitis) : Trousseau syndrome ( Migratory thrombophlebitis) Clinical Presentation: Clinical Presentation OTHERS Venous thrombosis Marantic endocarditis New onset of diabetes within 1 year in old age 1 st episode of acute pancreatitis in old age ……………………..:  …………………….. Rule out Pancreatic Cancer in patient older than 6 0 years with NEW diagnosis of DM or increase in insulin reqirement in pre existind diabetes and without any other diabetic risk factors ……………………………………:  …………………………………… Rule out pancreatic cancer in an elderly patient presenting for 1 st time with acute pancreatitis without any known precipitating factors Clinical Presentation-Examination: Clinical Presentation-Examination Epigastric Mass Non mobile, smooth, soft/hard, (non)tender, not moving with respiration Palpable gallbladder(+clinical jaundice) i.e. Courvoisier sign Nontender , soft globular, smooth, moving with respiration, mobile horizontally, dull on percussion 25-30 % cases of CA head of pancreas 50 % cases of periampullary CA Ascites Shifting dullness and fluid thrill Clinical Presentation: Clinical Presentation Hepatomegaly Enlarged+ smooth, firm and nontender  Hydrohepatosis Dilated bilairy channels Multiple hard nodules Mets Splenomegaly due to portal/splenic vein thrombosis Seen in 10 % cases Clinical Presentation: Clinical Presentation Sister Mary Joseph nodule(s)/node/sign Subcutaneous metastases Paraumbilical region Signifies advanced disease spread of cancer cells to the umbilicus include direct   transperitoneal spread , via the  lymphatics  which run alongside the obliterated  umbilical vein hematogenous spread, or via remnant structures such as the  faclciform ligament, median umbilical ligament, or a remnant of the  vitelline duct. Mass in rectovesical pouch( Blumer’s Shelf) Metastatic mass, palpable on DRE * Sister Mary Joseph Dempsey   was the surgical assistant of   William J. Mayo at   St. Mary’s Hospital n Rochester, Minnesota  from 1890 to 1915. She drew Mayo's attention to the phenomenon, and he published an article about it in 1928. The eponymous  term Sister Mary Joseph nodule was coined in 1949 by Hamilton Bailey. Clinical Presentation: Clinical Presentation Virchow’s node*( or Signal node) Called Troisier’s sign ** Left supraclavicular palpable lymph node Behind the medial end of left clavicle Right: Charles Émile Troisier Left: Rudolf Carl Virchow *  Rudolf Virchow(1821–1902), the German pathologist who first described the gland and its association with gastric cancer in 1848 . ** TheFrench  pathologist Charles Emile Troisier  noted in 1889 that other abdominal cancers, too, could spread to the node. Clinical Presentation: Clinical Presentation Sister Mary Joseph nodule Virchow/signal node Differential diagnosis: Differential diagnosis Retroperitoneal masss /tumor/LN Advanced adherent CA stomach Advanced CA transverse colon CBD stone Bile duct stricture LN compressing CBD Cholangiocarcinoma of CBD Chronic pancreatitis Workup: Workup Hematological Investigations Serological Investigations Radiological Investigations Histopathological investigation Hematological Investigations: Hematological Investigations CBC Anemia of chronic disease Thrombocytosis Liver Function Test Raised total/conjugated (van den Bergh’s test)bilirubin Raised ALP/GGTP Low albumin and altered PT/INR Serum amylase/lipase* Raised in < 50 % cases of resectable tumor v/s 25 % cases of irresectable tumor *5% cases present initially with acute pancreatitis Serological Investigations: Serological Investigations Carbohydrate Antigen(CA) 19-9 (<33-37 U/mL) Sialylated oligosaccharide most commonly found on circulating mucins in cancer patients Also normally produced within cells of biliary tract Can be elevated in 10% cases of benign diseases of pancreas, liver and bile ducts Elevated in 75-85 % cases of pancreatic CA 5-10 % patients lack CA 19-9 producing enzyme In absence of biliary obstruction, intrinsic liver disease, or benign pancreatic disease, value> 100 U/mL  highly specific for malignancy especially pancreatic Serological Investigations: Serological Investigations Carbohydrate Antigen(CA) 19-9 Used along with imaging studies to determine resectability potential <4% cases with CA 19-9 > 300 U/mL have resectable tumors Demerit: Least sensitive for small, early stage pancreatic carcinomas i.e. not effective as screening tool or early detection 0.2 % positive results in asymptomatic cases 4.3 % positive in early symptomatic cases Serological Investigations: Serological Investigations Carbohydrate Antigen(CA) 19-9 Used in staging and follow up Case with <100 U/mL  unlikely to have occult metastatic disease and may not need staging lapsroscopy prior to resection Surrogate marker for clinical response to therapy Preoperative >50 U/mL  associated with higher chances of recurrence Serological Investigations: Serological Investigations Carcinoembryonic antigen(CEA) High molecular weight glycoprotein found normally in fetal tissues Elevated in only 40-45 % of cases of pancreatic CA NOT sensitive or specific for pancreatic CA As it is also elevated in others benign and malignant conditions Sensitivity Specificity CA 19-9 NO YES CEA NO NO Radiological Investigations: Radiological Investigations Computed Tomography Scan Mainstay of initial diagnostic modalities used for assessing patients suspected to have pancreatic carcinoma Triple-phase spiral/3D CT scan 90 % accurate in determining resectability potential (as accurate as EUS) To detect size, extent, nodal status , portal vein involvement More accurate than EUS in predicting involvement of SMA Malignant tumors appear as lower density lesions CT guided FNA can also be done Demerit: Small tumors still be missed even with most advanced CT scanning CT scan findings suggestive of unresecatable disease: CT scan findings suggestive of unresecatable disease Invasion of hepatic artery or SMA Enlarged LN outside boundaries of resection Ascites Distant metastases CT scan showing a pancreatic adenocarcinoma: CT scan showing a pancreatic adenocarcinoma G allbladder ( gb ) is distended because of biliary obstruction. The superior mesenteric artery ( sma ) is surrounded by tumor, making this an unresectable T4 lesion.  2-cm pancreatic adenocarcinoma (mass) causing obstruction of both the common bile duct ( cbd ) and pancreatic duct ( pd ). Radiological Investigations: Radiological Investigations T ranscutaneous U ltra s onography Less useful than CT because pancreas is often obscured by overlying gas from stomach, duodenum and colon. Depth of pancreas from anterior abdominal wall limits imaging to lower(2-5 MHz) frequency, hence lower resolution Detect only 60-70 % of pancreatic CA >40% lesions <3 cm missed(similar to CT) Only useful as an initial screening test in evaluating patients who present with possible obstructive jaundice However, other studies should then be performed to definitively diagnose the source of biliary obstruction. Use to visualize gall bladder, liver , CBD size, LN, portal vein, ascites Radiological Investigations: Radiological Investigations E ndoscopic U ltra s onography Obviates the physical limitations of TUS High frequency USG(7.5-12 MHz) with very high resolution ( subcentimeter ) images INDICATED if high suspicion of pancreatic CA and CT is norma l MOST SENSITIVE and SPECIFIC diagnostic test for pancreatic cancer Negative EUS is nearly 100 % specific at ruling out presence of a pancreatic neoplasm Detection rates of 99-100 % for all pancreatic carcinomas including <3 cm As accurate as ERCP or MRCP for assessing etiology of obstructive jaundice Equivalent to dual-phase spiral CT for assessing tumor resectability potential Superior to CT as mean of assessing T stage of tumor e.g. portal vein/ SMV involvement EUS-guided FNA can also be done at time of EUS diagnosis Demerit: Inferior to CT in assessing arterial involvement and distant metastases Poor at detecting occult nodal involvement(same as CT) Endoscopic ultrasound of a 2.2-cm pancreatic adenocarcinoma of the head of the pancreas obstructing the common bile duct (CBD) but not invading the portal vein (PV) or superior mesenteric vein (SMV). : Endoscopic ultrasound of a 2.2-cm pancreatic adenocarcinoma of the head of the pancreas obstructing the common bile duct (CBD) but not invading the portal vein (PV) or superior mesenteric vein (SMV).  Radiological Investigations: Radiological Investigations E ndoscopic R etrograde C holangio p ancreatography Highly sensitive means of detecting pancreatic +/- biliary ductal abnormalities in pancreatic cancer 90-95 % cases have ERCP findings Brush cytology and forceps biopsy can be taken(< 50 % yield) Demerits: Findings not always highly specific for pancreatic cancer Difficult to differ from changes of chronic pancreatitis More invasive and carries 5-10 % risk of significant complications Reserved as therapeutic procedure for biliary obstruction OR for diagnosis of unusual neoplasm such as intraductal pancreatic mucinous neoplasms(IPMN) Limited staging information Radiological Investigations: Radiological Investigations M agnetic R esonant I maging NOT superior to spiral CT scanning in diagnosing and staging pancreatic cancer M agnetic R esonant C holangio p ancreatography Noninvasive method for imaging the biliary tree and pancreatic duct Radiological Investigations: Radiological Investigations P ositron E mission T omography Uses 18F-fluorodeoxyglucose(FDG) to image primary tumor and metastatic disease Useful in detecting occult metastatic disease Alone offer no additional benefits over high-quality CT PET-CT more sensitive than conventional imaging for detection of pancreatic cancer Needle Aspiration : Needle Aspiration IN FAVOUR Provide proof of pathology pre operatively Exclude unusual pathology Evidence of disease before initiation of multidisciplinary treatment e.g. neoadjuvant chemotherapy AGAINST Biopsy will not alter therapy May result in seeding*, infection, bleeding, fistula and leak Interfere with definitive surgery Increases the cost of care *Risk of peritoneal contamination with CT guided biospy (50-85 % yeild ) is uncommon *EUS guided aspiration done through tissue that would ultimately included in operative field and resected. Thus, it is MOST EFFECTIVE(85-95 % accurate) means for getting biopsy _____________________________________________________________________________ Needle Aspiration: Needle Aspiration Tissue diagnosis before performing pancreatoduodenectomy is not essential Negative biopsy doesn't rule out malignancy in face of clinical and radiological clues Tissue diagnosis mandatory if Neoadjuvant /adjuvant chemotherapy to be given Clinical presentation more suggestive of alternative diagnosis such as lymphoma or pancreatic islet cell tumors Staging: Staging Once probable diagnosis has been established, next issue is whether lesion is amenable to surgical resection Pancreatic masses characterized as Resectable ( only 20 % of all cases) Borderline resectable (based on experience/skill of surgeon and overall health of patient) Irresectable Noncurative resections for pancreatic cancer provide no survival benefits Hence, WHEN NOT TO OPERATE decision requires accurate preoperative staging American Joint Committee on Cancer (AJCC)- 2002: American Joint Committee on Cancer (AJCC )- 2002 Tumor (T) TX - Primary tumor cannot be assessed T0 - No evidence of primary tumor Tis - Carcinoma in situ T1 - Tumor limited to the pancreas, 2 cm or smaller in greatest dimension T2 - Tumor limited to the pancreas, larger than 2 cm in greatest dimension T3 - Tumor extension beyond the pancreas ( eg , duodenum, bile duct, portal or superior mesenteric vein) but not involving the celiac axis or superior mesenteric artery T4 - Tumor involves the celiac axis or superior mesenteric arteries Regional lymph nodes (N) NX - Regional lymph nodes cannot be assessed N0 - No regional lymph node metastasis N1 - Regional lymph node metastasis Distant metastasis (M) MX - Distant metastasis cannot be assessed M0 - No distant metastasis M1 - Distant metastasis T staging for pancreatic carcinoma: T staging for pancreatic carcinoma American Joint Committee on Cancer (AJCC)- 2002: American Joint Committee on Cancer (AJCC)- 2002 Stage T N M Description 0 Tis N0 M0 IA T1 N0 M0 Limited to pancreas≤ 2 cm IB T2 N0 M0 Limited to pancreas > 2 cm IIA T3 N0 M0 Extends beyond pancreas but doesn't involve arteries IIB T1-3 N1 M0 Any tumor without artery involvement with LN + III T4 Any N M0 Tumor involves arteries ( unresectable ) IV Any T Any N M1 Any tumor with distant metastases Stage grouping for pancreatic cancer is as follows : Staging: Staging Stage at time of presentation Frequency of cases Stage I disease-confined to primary site 7 % Locally advanced disease 26% Metastatic to distant nodes/sites 52% Unknown 15% Staging: Staging MODALITIES According to 2011 NCCN guideline, CT scan primary mean for staging Triphasic multidetector spiral(helical) dynamic contast -enhanced CT with thin-slice, cross sectional imaging is recommended i.e. pancreas protocol CT scanning EUS 70-80 % accurate for correct staging/predicting resecatbility Staging Laparoscopy (with US 98 % accurate) Some use it routinely in all patients with pancreatic caner Others, including NCCN 2011 guidelines, advise selective approach with any of following criteria: CA 19-9 > 1000 U/mL or marked wt loss Low volume ascites Body/tail of pancreas tumor Borderline resectable tumors/equivocal findings of metastsis Size> 4 cm CBD lymphadenopathy Doesnot show vascular invasion or retroperitoneal invasion which makes apparently resectable tumor irresectable one Evaluation Algorithm: Evaluation Algorithm Treatment: Treatment Surgery primary mode of treatment Chemoradiation Adjuvant or neoadjuvant therapy Irresectable disease Palliative therapy Treatment: Treatment SURGERY Typically, e xtrapancreatic disease precludes curative resection and surgical treatment may be palliative at best Invasion of SMV/portal vein NOT absolute contraindication Can be resected partially with as much as 50 % narrowing of lumen Complete reconstruction is possible e.g. using native veins as replacement( internal jugular, greater saphenous or splenic) Invasion of SMA/celiac/hepatic arteries still barrier to resection Treatment: Treatment SURGERY In operable cases Whipple Procedure Traverso -Longmire pylorus preserving pancreaticoduodenectomy (PPPD) Fortner’s regional pancreatectomy (extended whipple’s ) Total pancreatectomy Distal pancreatectomy In inoperable cases Roux en Y choledochojejunostmoy Whipple Procedure: Whipple Procedure Indicated for periampullary tumors Involves removal of Pancreatic head and neck 40 % distal stomach + C loop of duodenum + 10 cm proximal jejunum Lower end of CBD with gall bladder Peripancreatic + pericholedochal + paraduodenal + perihepatic nodes Contiuity maintained by Choledochojejunostomy Pancreaticojejunostomy ( or pancreatogastrostomy ) Gastrojejunostomy Whipple Procedure: Whipple Procedure Whipple Procedure: Whipple Procedure Mortality 2-8 % Complications Delayed gastric emptying-25 % Require NG decompression Pancreatic fistula -14 % Infection- intraabdominal abscess, wound infection, cholangitis, pancreatitis, pneumonia Bile/pancreatic anastomotic leak Preoperative biliary drainage (ERCP) increases the rate of complications Surgery: Surgery Traverso -Longmire pylorus preserving pancreaticoduodenectomy (PPPD) Duodenum is cut 2 cm distal to pylorus Continuity maintained by anastomosing with jejunum Fortner’s regional pancreatectomy (extended Whipple’s) Resection like whipple’s along with removal of segment of SMV and clearance of all regional nodes Portal vein continuity maintained by synthetic vascular graft Surgery: Surgery Total Pancreatectomy Least commonly performed procedure Morbidity comparable to that of whipple procedure Highest mortality rate i.e. 8.3 % Indicated in pancreatic neck tumor Merits: Possibility of multicentric disease Recurrence after whipple procedure No morbidity due to pancreatic fistula or pancreatitis Malignant cell may present in pancreatic duct Complication Severe resistant brittle diabetes mellitus Surgery: Surgery Distal Pancreatectomy Lower mortality(3.5 %) than standard whipple Indicated for tumor located in body and tail of pancreas Limited curative resection as these tumor present later with higher unresectability rate Involves isolation of distal portion of pancreas containing tumor followed by resection of that segment, with over sewing of distal pancreatic duct Complications: Pancreatic stump leak, hemorrhage, endocrine insufficiency Surgery: Surgery Roux en Y choledochojejunostomy Palliative procedure done along with gastrojejunostomy after doing cholecystectomy Better than cholecystojejunostomy as it may get blocked either by tumor infiltration or by bile sludge or inflammation Chemoradiotherapy-Palliative: Chemoradiotherapy -Palliative Indicated in advanced irresectable /metastatic pancreatic cancer Gemcitabine (1000 mg/m 2 over 1 hour IV) montherapy 1 st line therapy (NCCN 2011 guidelines) in poor performance status FOLFIRINOX ( LV5-FU + oxaliplatin + irinotecan ) 1 st line therapy (NCCN 2011 guidelines) in good performanc status Gamcitabine + nab(nanoparticle ablumin bound)-paclitaxel Indicated if FOLFIRINOX contraindicated Capecitabine +/- erlotinib Second line therapy if refactory to gemcitabine OTHERS Gamcitabine + docetaxel + capecitabine (GTX regimen) Gemcitabine +/- erlotinib -FDA approved / capecitabine (controversial ) Chemoradiotherapy-Palliative: Chemoradiotherapy -Palliative Daily use aspirin over a period of 5 years reduces death caused by several cancers including pancreatic cancer :  Chemoradiotherapy - Adjuvant Gemcitabine S-1( Taiho Pharmaceutical, Japan) Chemoradiation-Neoadjuvant No form of neoadjuvant therapy is regarded as standard form of therapy( NCCN 2011) Palliative Therapy: Palliative Therapy PAIN Nacrotic analgesics used early and in adequate dosages Combining with TCAs or antiemetics potentiate their analgesic effect Sustainted release Morphine sulfate Neurolysis of celiac ganglion if refactory pain Performed transthoracically or transabdominally by invasive radiology or anesthesiology, transgastrically using EUS-guided Fine needle injection or intra operatively Radiation therapy(4000 cGy units) can palliate pain but does not affect patients survival ERCP- stent if pain due to obstruction of pancreatic/ bilairy tract Palliative Therapy: Palliative Therapy JAUNDICE Warrants palliation if patient has pruritus or RHC pain or developed cholangitis Endoscopic placement of plastic(replace every 3 months) or metal (5 months) stents Surgical biliary decompression/bypass DUODENAL OBSTRUCTION-20% Endoscopic stenting(poor operative candidates) Gastrojejunostomy PROGNOSIS…….fatal disease: PROGNOSIS……. fatal disease 5 year survival after successful surgery  NOT guarantee of CURE Without Surgery Successful curative resection (about 20 % patients) Median survival rate 4-6 months 12-19 months 1 year survival rate 24 % Overall 5 year survival rate 5 % 15-20 % Location Time of presentation Prognosis HEAD and NECK Early presentation-obstructive jaundice Better prognosis Body and Tail Late presentation(Mass) Worse prognosis PROGNOSIS…….fatal disease: PROGNOSIS……. fatal disease Stage 5 year survival rate Localized stage 20.3 % Regional stage 8.0 % Distant stage 1.7% Unknown stage 4.1% PROGNOSIS…….fatal disease: PROGNOSIS……. fatal disease POOR PROGNOSTIC FACTORS Growth > 3 cm* Nodal involvement* Ratio of positive nodes to total nodes removed more important than margin positivity Portal vein infiltration Liver /Lung mets * Ascites*/Trousseau’s sign/Left supraclavicular LN spread White bile on table Associated problems like pancreatitis, DM Liver dysfunction* *Present in patient mentioned in case summary Future Therapy: Future Therapy Immunotherapeutic gene therapy To assist immune system in recognizing cancer cells Replacement of tumor suppressor gene function Inactivation of oncogenes Suicide gene therapy Transgene introduced that converts an inactive notoxic drug into active cytotoxic agent E.g. Herpes simplex virus-thymidine kinase system Case Summary: Case Summary 60 year old male, resident of Nankana Sahib presented with pain in epigastrium for last 1 year, chronic in onset, progressive, boring in nature, radiating directly to back, aggravated with food intake, relieved temporarily with medication, mild initially then moderate in intensity, associated weight loss, anorexia, yellowish discoloration of sclera, dark color urine, abdominal distension Past medical history shows HCV + with chronic liver disease Examination revealed elderly male of lean physique with abdominal distension, vitally stable, with Jaundice +, BUT no pallor/bruises/palpable lymphadenopathy Abdominal Examination revealed it to be distended, tensed, tender(upper portion) with horizontally compressed umbilicus, splenomegaly, fluid thrill +, NO paraumblical nodule Case Summary: Case Summary Hematological investigations showed Parameter Value Hemoglobin 13.5 Total leucocyte Count 6.2 Platelet count 172 Sodium/potassium 137/3.8 Urea/ creatinine 70/0.9 Prothromin time 14/13 (INR 1.1) Total bilirubin 14.2 Conjugated bilirubin 11.0 Alkaline phosphatase 340 Gamma GT 202 Total protein/ Albumin 5.6/ 2.0 ALT/AST 46/41 Case Summary: Case Summary Transcutaneous Ultrasound showed Liver normal in size and echotexture.No focal lesion seen Biliary channels/CBD/portal vein normal Gall Bladder distended full of thick sludge and debrinous Pancreas showed 46x24x57 mm heterogenous area into body and tail Spleen measures 14.5 cm and mildly enlarged Minimal abdominopelvic ascites Case Summary: Case Summary Pancreas protocol CT scan showed Infiltrative primary pancreatic mass involving its body and tail which would be most concerning for a primary pancreatic cancer. Associated upper abdominal lymphadenopathy Significant intra and extra hepatic biliary dilation probably secondary to upper abdominal lymphadenopathy Gall Bladder distended with no primary GB mass Obvious slightly irregular focal low density in segment 4 of liver , most consistent with liver metastases Significant abdominopelvic ascites Nodularity/thickening along peritoneal reflection and omental infiltration Multiple basal pulmonary nodules regarded as metastasis Sclerotic focus in right ischial bone, may represent bone mets ___________________________________________________________ IMPRESSION: Metastatic primary T4 pancreatic cancer (Stage 4) Case Summary: Case Summary Currently, patient is on following treatment Rationale Medication Partial Parenteral Nutrition Inf 10 % D/W 1000 ml IV OD Inf Aminovil 500 mg IV BD Pain Inj Toradol IV TDS Inj N/M diluted in 10 ml N/S, give 3 ml IV TDS Vomiting Inj gravinate IV TDS Inj Onset IV TDS Stress ulcers Inj Novoteph 40 mg IV BD Antibiotic Inj oxidil 1g IV BD Ascites Inj Lasix 20 mg IV OD Tab aldactone 100 mg PO OD Tab Inderal 10 mg PO TDS Inj Albumin 100 ml IV OD for 3 days Malabsorption of vit K(fat soluble) Inj Vit K IM OD for 3 days Case Summary: Case Summary As a palliative measure for biliary decompression, ERCP planned on 24 th March 2014 THANK YOU…………………..: THANK YOU………………….. Surgical Triad: Surgical Triad Measure Thrice Think twice Cut once

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