Pancreatic Cancer

Facts

Most lethal and aggressive form of cancer; makes up 95% of all pancreatic cancers; arises from exocrine pancreas

Incidence

62210

Mortality

49830

Status as cancer-related death

Fourth leading cause of cancer-related deaths

Typical pattern of metastasis

Head, body, tail, regional lymph nodes, liver, and lung

Also duodenum, stomach, colon, peritoneal cavity

Modifiable risk factors

Tobacco use (25% increase)

Obesity

Inactivity

Exposure to heavy metals, benzidine, pesticides, asbestos, benzene (dry cleaning and metal working)

Alcohol

Poor diet

Wide abdominal girth

Periodontal disease

Nonmodifiable risk factors

70 years of age

African American (50-90%)

Male gender

Family history

BRCA 1, BRCA2, PALB2 (Inherited breast and ovarian cancer syndrome)

Lynch syndrome

FAP

PJS

Familial atypical multiple mole melanoma

Hereditary pancreatitis

Cystic Fibrosis

Ataxia-telangiectasia

Diabetes 1 & 2

Pancreatitis

Liver Cirrhosis

Prevention

Avoid tobacco

Healthy weight

Regular exercise

Limit alcohol

Limit chemical exposure

Diagnosis

• clinical presentation

• Pancreatic protocol CT (tumor in relation to blood vessels for surgery planning)

• Multidisciplinary review

• CT or EUS guided Biopsy

• Histologic confirmation required

• Chest CT

• Biomarker CA 19-9

• Molecular profile KRAS

• Germline testing

Histopathology

• adenocarcinoma vs. neuroendocrine tumor(rare, better prognosis)

Median OS for nonresected patients

3.5 months

Survival for Stage 1

13%

Survival for Stage 4

1%

Disease classification for management

Resectable, borderline resectable, locally advanced unresectable, disseminated

Whipple Procedure

• head of pancreas

• Duodenum

• Portion of common bile duct

• Gallbladder

• Sometimes portion of stomach

Distal pancreotomy

• tail and portion of body are removed but not the head

Total pancreatectomy

Entire pancreas and spleen are removed (rate)

Radiation use

• Neoadjuvant with chemo or stereotactic body radiation therapy

• Adjuvant with chemo

Systemic therapy as adjuvant

• gemcitabine, 5-FU, gemcitabine/capecitabine

Systemic therapy for unresectable or metastatic cancer

FOLFIRINOX, gemcitabine/nab-paclitaxel, gemcitabine/cisplatin(BRCA1, BRCA2, PALB2)

Second line FOLFOX, 5-FU/Nal-irinotecan

Pembrolizumab - MSI-H, dMMR, NTRK gene fusion