Carcinoma of

Pancreas

Guide
Dr. M.K Chouhan

Introduction
4th

leading cause of cancer death U.S.

World

wide over 2,00,000 People die annually.

Non-specific

symptoms, inaccessibility to examination,

aggressiveness, technical difficulties associated with surgery.

Epidemiology/Risk Factors
Increase threefold since the beginning of the century.
Age

> 80 % of cases between 60-80 year of age.

Sex

Men > Women.

African-American of both sexes

Epidemiology/Risk Factors
Cigarette Smoking.
Chronic Pancreatitis.
Type II diabetes mellitus.
Cystic fibrosis.
Pernicious anemia.
Thyroid Cancer.

Increase Consumption of

Total Calorie
Carbohydrate
Cholesterol
Meat
Salt
Fried food
Nitrosamines

Epidemiology/Risk Factors
Protective effect for

Dietary fiber

Vitamin C

Fruits

Vegetables.

Epidemiology/Risk Factors
Genetic syndromes associated with an increased risk of

pancreatic cancer are:

HNPCC

FAMMM Syndrome

PJ syndrome

BRCA-2 associated with

Hereditary pancreatitis

Ataxia telangiectasia

familial breast cancer

Molecular Genetics
Tumor suppressor genes

p53 (Most common)

p16

DPC4
BRCA2.

Oncogenes

K-ras mutation
(most common)

HER-2/neu over expression

Pathology
Ductal adenocarcinomas - most common epithelial

tumor : Head, neck, or uncinate process

- 65 %

Body or tail

- 15 %

Diffuse

- 20%

Cont.
Adenocarcinomas: 75%, white yellow, poorly defined, often

obstruct bile duct or main pancreatic duct.

Often associated with a desmoplastic reaction that causes

fibrosis and chronic pancreatitis.

Cont.
Invasion

Metastasis

Vascular

Liver

Lymphatic

Peritoneum

Perineural Space

Lungs & Pleura

Adjacent organs

Adrenal

Cont.
Other Histological type

Acinar

Adenosquamous

Giant cells

Pancreatoblastoma

Cont.
Non epithelial tumor are :

Leiomyosarcomas

Plasma cytomas

Liposarcomas.

Hemangiopericytomas

Fibro sarcomas

Histiocytomas

Lymphomas

Cont.
Site of metastases from other primaries

Kidney

Stomach

Breast

Colon

Lung

Germ Cell

Melanoma

Clinical Presentation
Inability to make diagnosis at early stage.
Specific symptoms occur after invasion of adjacent

structures.

Cont.
Pancreatic Head

Jaundice(82%)

Abdominal pain(72%)

Clay Colored Stool(62%)

Weight Loss(92%)

Dark Urine (63%)

Vomiting

Pruritus (24%)

Nausea (37%)

Acute pancreatitis

Anorexia (64%)

New onset DM

Fatigue

Anemia due to GI bleed

Cont.
Pancreatic body or tail

Weight Loss(100%)

Abdominal Pain(87%)

Anorexia

Jaundice (Less common)

Cont.
Signs of advanced Cancer

Nodular Liver

Sister Mary Josephs node

Blumers shelf

Virchows node

Malignant ascites

Preoperative investigations &

Preparation
Goals

Identification of tumor and location

Resectability and need for vascular resection

Rule out locally advanced and metastatic disease

Assess fitness for major resection

Blood Investigations

Total Bilirubin

Serum Alkaline phosphatase

Prothrombine Time

Amylase - Normal

Lipase -Normal

Cont.
Serum maker

CA-19-9

CEA

CA 19-9, when upper level cutoff is used >200U/mL,

accuracy is 95% in diagnosing pancreatic cancer.

With CT, ERCP, US and CA19-9 together, it approaches

100%.

Higher levels correlate with prognosis and tumor

recurrence, unresectability

Imaging

USG

PTC

CT

EUS

MRI (with or without

PET scan

MRCP)

ERCP

USG

Screening Method

Site and etiology of obstruction

Differentiation of cystic lesions in liver V/s

metastatic

Guided FNAC in unresectable cases.

Cont....

Pancreatic tumour appears as a hypoechoic (poorly

reflective) nodule as compared to the rest of pancreas

USG is highly sensitive to detecting

Peripancreatic nodes
Liver nodules
Ascites

CECT

Detection of tumour

Assessment of resectability
Sensitivity

93 - 100 %

ERCP

Anatomy & for Biopsy

Sensitivity

Long irregular stricture in an otherwise normal duct is

90%

highly suggestive.

Causing an abrupt amputation of a dilated CBD, main

pancreatic duct or both(double duct sign)

Obstruction with no distal filling.

Cont.
Indications :

If suspect cancer but no mass seen on CT.

Symptomatic but no jaundice and no mass

Chronic pancreatitis patients with development of mass.

Endoscopic USG

Help detection of small tumour < 25 mm

Most sensitive for nodal spread

Identification of nature of lesion and lymph node

differentiation from inflammatory head enlargement

FNA of enlarged nodes and cystic lesions.

Endoscopic US

Pre operative biliary

drainage

Sick, malnourished poor performance status.

Cholangitis

Renal failure, coagulopathy or severe co-morbidity

Preoperative Staging
Determine feasibility of surgery and optimal treatment

for each individual patient.

In many cases only CT scan is necessary.

Cont.
Absence

of

metastases,

patent

SMV-portal

vein

confluence, no direct extension to celiac axis or SMA

accuracy for resectability 85%.
For tumors of the neck, head, uncinate process,

occlusion of the SMA or portal vein along with presence

of

periportal

unresectability.

collateral

vessels

is

sign

of

Cont.
In contrast tumors of the body and tail, occlusion of the

splenic vein with perigastric collaterals does not always

preclude resection.
The extent of further staging depends on the patient and

surgeon. If findings of staging can prevent an operation

and lead to non-operative palliation, these efforts are
worthwhile.

Cont.
Endoscopic US useful for small lesions, lymph nodes,

vascular invasion, EU guided FNA may avoid seeding.

Cont.
Diagnostic laparoscopy on potentially resectable

patients may find mets to liver and peritoneum not

seen on CT because they are small. 50% of tumors of
body and tail will have unexpected mets to
peritoneum, whereas in head and neck, only 15%
unexpected mets seen.

Cont.
At the time of diagnosis, only 10% tumors confined to

pancreas. 40% have locally advanced disease, 50%

distant spread. Overall only 10-20% of all patients are
candidates for pancreatic resection.

Tissue Diagnosis
Percutaneous FNA should not be used on potentially

resectable tumors for two reasons.

Even if the result is negative it does not rule out

malignancy, in fact the small, potentially curable
lesions
will be the ones that are missed by the needle.

Potential for seeding along tract or intraperitoneally.

Cont.
FNA should be done on patients deemed unresectable for

direction of chemotherapy, or patients in whom neoadjuvant

chemo is being considered. Currently EUS is the preferred
technique for this in these situations.

Clinicopathologic Staging
T1 limited to pancreas, 2cm or less in size.
T2 limited to pancreas, >2cm.
T3 extends beyond pancreas, but not celiac or SMA.
T4 involves celiac or SMA (unresectable).
N0, N1
M0, M1

Complete Resection
R Status
R Designation Gross Resection Microscopic Margin
R0
R1
R2

Complete
Complete
Incomplete

Negative
Positive
Positive

Exocrine Pancreas. In Greene FL, Page DL, Fleming ID, et al., eds.
AJCC Cancer Staging Manual. Chicago, IL: Springer, 2002. pp.
157-164.

 Resectable:
no extension to celiac, CHA, SMA
patent SMV-PV confluence
stage I, II (T1-3, Nx, M0)
Locally Advanced:
celiac, SMA encasement (> 180)
stage III (T4, Nx, M0)
Borderline:
arterial abutment (< 180)
stage III (minimal T4)
Varadhachary GR, et al. Ann Surg Oncol.
2006;13(8):1035-46 Katz
MHG, et al. J Am Coll Surg.
2008;206(5):833-46

Suspected Pancreatic Ca
Resectable

Surgery

Helical CT

Locally advanced Borderline

resectable
EUS with FNA
Chemo/XRT

Distant Mets

EUS+ FNA
Chemo Rx
Palliation

EUS
+/- MRI
Laparoscopy
+/- Neoadjuvant Rx

Surgery
Five basic techniques are used to resect pancreatic cancers.

Classic pancreaticoduodenectomy (Whipple Procedure)

Pylorus preserving pancreaticoduodenectomy

Total pancreatectomy

Regional pancreatectomy

Extended resection (MD Anderson)

Resection of Pancreatic
Carcinoma
1935- Whipple described a technique for radical excision

of a periampullary cancer.
Was originally performed in two stages, first stage was a

cholecystogastrostomy and gastrojejunostomy. Second

stage was done after nutritional status better and jaundice
improved. En-bloc resection of second portion of
duodenum, head of pancreas done without reestablishing
pancreas-GI continuity.

Cont..
Since then many modifications done.
Operative management of pancreatic cancer consists of

two phases: first assessing tumor resectability, second

completing a pancreaticoduodenectomy and restoring
GI continuity.

Cont
1.

Search first for mets, extra pancreatic involvement.

Send frozen sections on suspect lesions.

2.

Assess primary tumor, for resectability, look for IVC,

Aorta, SMA, SMV, Portal vein. A Kocher maneuver is
done to mobilize duodenum and head from IVC and
aorta, once mobilized can assess relationship of tumor
to SMA. Inability to find a plane between pulsation of
SMA and tumor means unresectable.

Cont
3.

Dissect out SMV and Portal vein to rule out tumor

invasion.

4.

Once this is negative go to pancreaticoduodenectomy

(pylorus preserving or classic).

Kocherization

Determining Resectability

Resected Head

Complications of Whipple
Procedure
Delayed gastric

emptying
Operative site

haemorrhage
Intra-abdominal

abscess
Pancreatic fistula

Wound Infection
Cholangitis
Bile leak
Pneumonia
Pancreatitis
Marginal Ulcer

Complications

Pylorus Preserving
Introduced in 1978 in an attempt to eliminate

postgastrectomy syndromes.
It does not adversely affect local control or survival.

Blood loss and operative time less.

Only differs in that blood supply to proximal duodenum

is preserved (preserve right gastroepiploic arcade after

ligation of gastroepiploic artery and vein at its origin).

Pylorus Preserving

Distal Pancreatectomy
Pancreatic body cancer
Pancreatic tail cancer

Palliation
Obstructive Jaundice

Operative

Non operative

Hepaticojejunostomy

Cholecystojejunostomy

Stent placement

Duodenal Obstruction

Operative

Gastrojejunostomy

Non operative

Expandable Metallic bowel

stents

Cont.
Pain

Operative

Chemical splanchnicectomy

Non operative

Celiac plexus block

Adjuvant Therapy
5 FU, Gemcitabine.
Radiotherapy.

Adjuvant Therapy
Autopsy series show that 85% of patients will

experience recurrence in operative field.

70% have metastases to liver.
So need to address local control (radiation) and distant

disease (chemotherapy).
Most commonly used is 5 FU and this only has a 15-

28% response on its own, but its a radiosensitizer, so it

improves response to radiotherapy.

Prognosis
Little change in survival.
Remains less than 25% over 5 years
Median survival in 20 months
Body and tail have worse prognosis because detected

late, advanced disease.

5-Year Survival
Stage 1A, 1B (T1-T2, N0, M0)20-30%.
Stage 1B (T2, N0,M0) 20-30%.
Stage 2A (T3, N0,M0) 10-25%.
Stage 2B (T1, T2, T3, N1, M0)10-15%.
Stage 3 (T4, any N, M0) 0-5%.
Stage 4 (Any T, any N, M1) 0%.

Summary
Local tumor resectability is best determined by high

quality CT.
Resectable tumors may be treated with upfront surgery or

a neoadjuvant approach
Borderline resectable tumors are best treated with upfront

systemic therapy/chemoradiation
Locally

advanced tumors, as defined by arterial

encasement, are not resectable and surgery is

realistic treatment option

not a

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