Pancreatic Carcinoma (General Surgery EOR - Smarty PANCE)

Define pancreatic carcinoma

Adenocarcinoma of the pancreas arising from duct cells

What are the associated risk factors for pancreatic carcinoma?

Smoking 3 x risk, diabetes mellitus, heavy alcohol use, chronic pancreatitis, diet high in fried meats, previous gastrectomy

What is the male to female ratio for pancreatic carcinoma?

3:2

What is the African American to white ratio for pancreatic carcinoma?

2:1

What is the average age of dx for pancreatic carcinoma?

> 60

What are the different types of pancreatic carcinoma?

> 80% are duct cell adenocarcinomas; other types include cystadenocarcinoma and acinar cell carcinoma

What percentage of pancreatic carcinoma arise in the pancreatic head?

66% arise in the pancreatic head; 33% arise in the body and tail

Why are most pancreatic cancers in the tail nonresectable?

These tumors grow without symptoms until it is too late and they have already spread—head of the pancreas tumors draw attention earlier because of biliary obstruction

What are the signs/symptoms of pancreatic tumors based on location: Head of the pancreas?

Painless jaundice from obstruction of common bile duct; weight loss; abdominal pain; back pain; weakness; pruritus from bile salts in skin; anorexia; Courvoisier's sign; acholic stools; dark urine; diabetes

What are the signs/symptoms of pancreatic tumors based on location: Body or tail?

Weight loss and pain (90%); migratory thrombophlebitis (10%); jaundice ( 10%); nausea and vomiting; fatigue

What are the most common symptoms of pancreatic cancer of the pancreatic HEAD?

1. Weight loss (90%) 2. Pain (75%) 3. Jaundice (70%)

What is "Courvoisier's sign"?

Palpable, nontender, distended gallbladder

What percentage of patients with cancers of the pancreatic HEAD have Courvoisier's sign?

33%

What is the classic presentation of pancreatic cancer in the head of the pancreas?

Painless jaundice

What metastatic lymph nodes described classically for gastric cancer can be found with metastatic pancreatic cancer?

Virchow's node; Sister Mary Joseph's nodule

What are the associated lab findings in pancreatic carcinoma?

Increased direct bilirubin and alkaline phosphatase (as a result of biliary obstruction) Increased LFTs Elevated pancreatic tumor markers

Which tumor markers are associated with pancreatic cancer?

CA-19-9

What does CA-19-9 stand for?

Carbohydrate Antigen 19-9

What diagnostic studies are performed for pancreatic carcinoma?

Abdominal CT, U/S, cholangiography (ERCP to rule out choledocholithiasis and cell brushings), endoscopic U/S with biopsy

What are the pancreatic cancer STAGES: Stage I?

Tumor is limited to pancreas, with no nodes or metastases

What are the pancreatic cancer STAGES: Stage II?

Tumor extends into bile duct, peripancreatic tissues, or duodenum; there are no nodes or metastases

What are the pancreatic cancer STAGES: Stage III?

Same findings as stage II plus positive nodes or celiac or SMA involvement Stage

What are the pancreatic cancer STAGES: Stage IVA?

Tumor extends to stomach, colon, spleen, or major vessels, with any nodal status and no distant metastases

What are the pancreatic cancer STAGES: Stage IVB?

Distant metastases (any nodal status, any tumor size) are found

What is the treatment of pancreatic cancer based on location:

Head of the pancreas?

Body or tail?

Whipple procedure (pancreaticoduodenectomy)

Body or tail: Distal resection

What factors signify inoperability in pancreatic cancer?

Vascular encasement (SMA, hepatic artery)

Liver metastasis

Peritoneal implants

Distant lymph node metastasis (periaortic/celiac nodes)

Distant metastasis

Malignant ascites

Is portal vein or SMV involvement an absolute contraindication for resection?

No—can be resected and reconstructed with vein interposition graft at some centers

Define the Whipple procedure (pancreaticoduodenectomy)

Cholecystectomy

Truncal vagotomy

Antrectomy

Pancreaticoduodenectomy—removal of head of pancreas and duodenum Choledochojejunostomy—anastomosis of common bile duct to jejunum

Pancreaticojejunostomy—anastomosis of distal pancreas remnant to jejunum

Gastrojejunostomy—anastomosis of stomach to jejunum

What is the complication rate after a Whipple procedure?

25%

What mortality rate is associated with a Whipple procedure?

5% at busy high volume centers

What are the possible post-Whipple complications?

Delayed gastric emptying (if antrectomy is performed); anastomotic leak (from the bile duct or pancreatic anastomosis), causing pancreatic/biliary fistula; wound infection; postgastrectomy syndromes; sepsis; pancreatitis

Why must the duodenum be removed if the head of the pancreas is resected?

They share the same blood supply

What is the postoperative adjuvant therapy?

Chemotherapy + XRT

What is the palliative treatment if the tumor is inoperable and biliary obstruction is present?

PTC or ERCP and placement of stent across obstruction

What is the prognosis at 1 year after diagnosis in pancreatic cancer?

Dismal; 90% of patients die within 1 year of diagnosis

What is the survival rate at 5 years after resection in pancreatic cancer?

20%