U.M.F. GR.T.

POPA IASI
`
The neoplasia of the digestive
tube: the diagnostic of the solide
tumors of the exocrine pancreas

Author: Tibuleac Alexandra




The neoplasis of the digestive tube are
frequently diagnosed in advanced
stages when the oncological treatment
is hard to approach.The diagnosis is
made sometimes by chance, due to
some other medical conditions.
One of the most difficult neoplasia of
the digestive tube to identify is the
solid tumor of the exocrine pancreas,
as it is usually diagnosed in advanced
stages.
Another issue that interferes with the
diagnose of this kind of tumor is the
fact that many times it can be
confused with the psedotumoral form
of the chronic pancreatitis.
Chronic pancreatitis- pseudotumoral
form
Chronic pancreatitis is commonly defined
as a continuing chronic inflammatory
process of the pancreas, characterized by
irreversible morphological changes. This
chronic inflammation can lead to chronic
abdominal pain and/or impairment of
endocrine and exocrine function of the
pancreas.

The neoplasia of the exocrine
pancreas

Ductal carcinoma represents 90% of the exocrine
tumors i 75% of all malignant tumors of pancreas.

Kevin G. Burnand, Anthony E. Young - The New Airds Companion in Surgical Studies 2-nd edition, 1999,
pag.962-963;

The fifth cause of mortality through cancer in men
(after lung, colon and prostate cancer)

Isselbacher, Fauci, Braunwald, Martin, Wilson Harrison Ediia a 14-a, Editura Teora, 2004

The fifth cause of mortality through cancer in
women( after breast, lung, colon, genital cancer)

Isselbacher, Fauci, Braunwald, Martin, Wilson Harrison Ediia a 14-a, Editura Teora, 2004
Material and method

The study is based on the analyze of
cases from the third hospital of
surgery, in the period January 2000
December 2004.


Material and method
798 cases with
pancreatitis affections


91 cases pseudotumoral
form
of the chronic pancreatitis


212 cases of neoplasia
of the exocrine pancreas
Material and method

Demographic parameters
Risk factors
Date clinice
Date paraclinice (de laborator, imagistice,
anatomie patologic)
Controale postoperatorii
Sex distribution of the pseudotumoral
form of the chronic pancreatitis
Women
27%
Men
73%
Demographic distribution of the pseudotumoral
form of the chronic pancreatitis
Rural
areas
40%
Urban
areas
60%
Age and sex distribution of the pseudotumoral
form of the chronic pancreatitis
0
2
4
6
8
10
12
14
<29 30-39 40-49 50-59 60-69 70-79 >80
Women Men
Bad habits for the patient with the
pseudotumoral form of the chronic pancreatitis
Alcohol
27%
tobacco
8%
Tutun&
Alcool
27%
Denies the
use of
alcohol
38%
Ponderea antecedentelor personale
patologice n pancreatita cronic
pseudotumoral
8%
5%
3%
26%
18%
40%
Ulcer duodenal
Pseudochist
Ulcer duodenal&
Hepatita cronica
Pancreatita acuta
Pancreatita acuta&
Pseudochist
Diabet zaharat
Localizarea durerii n pancreatita
cronic pseudotumoral
Durere in
hipocondrul
stang
7%
Durere
abdominala
superioara
25%
Durere
iradiata
posterior
9%
Durere in
hipocondrul
drept
21%
Durere
epigastrica
38%
Simptomele asociate durerii n
pancreatita cronic pseudotumoral
Scadere
ponderala
29%
Greturi&
Varsaturi
23%
Icter
16%
Scaune acolice
8%
Astenie
24%
Imagistica in diagnosticul
pancreatitei cronice pseudotumorale
Anul Nr.pacienti ECHO CT IRM ERCP
2000 22 19 3 0 4
2001 5 2 5 0 1
2002 15 13 6 4 0
2003 8 8 3 0 0
2004 13 13 10 2 0
Total 63 55
87%
27
43%
6
9,5%
5
8%
DISTRIBUIA PE SEXE A
NEOPLASMULUI PANCREASULUI
EXOCRIN
Sex feminin
49%
Sex
masculin
51%
In conformitate cu datele prezentate de :
Andren-Sandberg A. Demographics of exocrine pancreatic cancer with special reference to age, sex and time tends, Int J Pancreatol, 1993; 214-6
Backman PL, Barlow L, Andren-Sandberg A Decreasing incidence of exocrine pancreatic cancer in Sweden, Int J Pancreatol 1995; 18:289-90.
Bourhis J, Lacaine R, Augusti M, Huguier M Protective effect of estrogen in pancreatic cancer, Lancet, 1987.

Distribuia demografic a
neoplasmului de pancreas exocrin
RURAL
53%
URBAN
47%
Maruchi N, Brian D, Ludwig J Cancer of the pancreas in Olmsted County, Minnesota, 1935-1974, Mayo Clin Proc, 1979; 54:245-9.
Royall D, Jeejeebhoy KN, Taylor BR Nutritional status and function in patients following Whipple procedure compared with controls,
J Am Coll Nutr, 1996; 15:73-8.
Distributia pe grupe de varsta si sex a
pacientilor cu neoplasm de pancreas
exocrin
0
5
10
15
20
25
30
35
40
<29 30-39 40-49 50-59 60-69 70-79 >80
Sex feminin Sex masculin
In conformitate cu :
Maruchi N, Brian D, Ludwig J Cancer of the pancreas in Olmsted County, Minnesota, 1935-1974, Mayo Clin Proc, 1979; 54:245-9.
Smith PE, Krementz ET, Reid RJ An analysis of 600 with carcinoma of the pancreas, Surg Gynecol Obstet, 1967, 124:1288-96.
Pitt HA Curative treatement for pancreas neoplasms. Standard resection, Surg Clin North Am, 1995; 75:891-904.

Distribuia factorilor de risc ai
neoplasmului pancreasului exocrin
Alcool
21%
Tutun
5%
Neaga
consumul
57%
Tutun &
Alcool
17%
Sediul durerii n neoplasmul de
pancreas exocrin
0
10
20
30
40
50
60
70
Epigastric
Hipocondru
stang
Hipocondru
drept
Abdominal
superior
Simptome asociate durerii n
neoplasmul de pancreas exocrin
Simptom Nr.Cazuri Procente(%)
Urini hipercrome &
scaune acolice
52 12,35
Greuri & vrsturi 50 11,87
Icter 105 24,94
Prurit 39 9,29
Scdere ponderal 102 24,22
Astenie & inapeten

73 17,33
The pseudotumoral form of the
chronic pancreatitis
In population studies, males are affected
more commonly than females (6.7 vs 3.2 per
100,000 population).

Rates in males peak at age 45-70 years and
then decline; female rates reach a plateau,
which remains stable after age 35 years.

Sex differences with respect to etiology also
exist. Alcohol-induced illness is more
prevalent in males, idiopathic and
hyperlipidemic-induced pancreatitis is more
prevalent in females, and equal sex ratios are
observed in chronic pancreatitis associated
with hereditary pancreatitis.


The neoplasm of the exocrine
pancreas
affects in equal proportions both men and
women, despite the area from which they
belong (urban/rural);
the angle of incidence is between 60-80 years
old;
At women the incidence grows after
menopause (the protective role of estrogen);
The diagnose is late because the primary
symptoms, abdominal pain and jaundice,
appear in the advanced stages of the illness;
The neoplasm of the exocrine
pancreas
At the point of diagnose, 90% of the pacients
are already in the state of ganglionic,
lymphatic invasion and/or metastatic;
It can have as a first sign the debut of the
diabetului zaharat, after 60 years or more,
without obesity and with a fast evolution
towards the insulin dependence;
the tumore manifests when it has large
dimensions, extension in nearby tissues and
metastasis, and it can not be , usually,
resected ;
Neoplasmul de pancreas exocrin
ecographie has its limits: only to 69,42% of
the pacients the echo investigation helped to
identify the tumorale system;
explorarea intraoperatorie rmne metoda
cea mai bun de diagnostic, stadializare i de
apreciere a rezecabilitii;
ecografia intraoperatorie ar trebui s intre n
arsenalul uzual al oricrei intervenii n sfera
pancreatic. Combinat cu explorarea
manual reprezint metoda cu cea mai mare
acuratee diagnostic.

Pancreatita cronic pseudotumoral
vs neoplasmul pancreasului exocrin
diagnosticul diferenial ntre pancreatita
cronic pseudotumoral i neoplasmul de
pancreas exocrin este dificil de realizat chiar
si computer tomografic;
computer tomografia rmne nsa cea mai
important metod imagistic ce poate da
relaii asupra tumorii, raporturilor acesteia
cu structurile nvecinate, adenopatiilor,
metastazelor hepatice.
Pancreatita cronic pseudotumoral
vs neoplasmul pancreasului exocrin
endoscopia retrograd colangiopancreatic
este metoda golden standard pentru
localizarea cefalic a tumorilor solide
pancreatice cu rsunet asupra cilor biliare i
pancreatice,
rezonan magnetic imagistic are o
contribuia limitat n diagnosticul
diferenial al tumorilor solide pancreatice iar
costurile relativ crescute o fac s nu fie
utilizat de prim intenie.


Pancreatita cronic pseudotumoral
vs neoplasmul pancreasului exocrin
Rezonana magnetic
colangiopancreatografic (MRCP) este o nou
metod neinvaziv de diagnostic a
modificrilor ductului pancreatic, biliar i a
organelor adiacente n diferite axe.
Puncia biopsie intraoperatorie, eventual
ghidat ecografic, poate trana diagnosticul
anatomopatologic n prezena unei mase
tumorale pancreatice, chiar daca este grevat
de unele riscuri i accidente