34. Pancreatic adenocarcinoma Flashcards
what are the genetic etiology of pancreatic adenocarcinoma ?
genetic : 10 percent
familial pancreatic cancer= BRCA2
heriditory pancreatitis = prss1 , spink1
Lynch syndrome,
also known as hereditary non-polyposis colorectal cancer (HNPCC)
heriditary breast and ovarian cancer
peutz jeghers syndrome
others :
genetic mutation in p16 and ATM and
what are the acquired risk factors ?
smoking obesity type1 and 2 dm chronic pancreatitis- alcohol h pylori hep b RED MEAT saturated fat and processed food !
sodchhrs
pancreatic cancer mainly arise from what anatomical part ?
pancreatic head
what are the precursor lesions for pancreatic cancer ?
microscopic pancreatic intraepithelilal neoplasia
mucinous cystic neoplasma
what are the clinical signs and symptoms of pancreatic cancer?
belt shaped epigastric pain which may radiate to the back
courvoiser sign: ifpancreatic tumor in the head - enlarged non tender gall bladder and painless jaundice
malabsorption diarrhea , steatorrhea
dark urine
prurtitis
new onset diabetes
gastroduodenal obstruction
supercifical thrombophlebitis
what are the diagnosisi of pancreatic cancer ?
CA-19-9
false postive and adenoocarcinoma of the intestines , pancreatitis , polyps
however preoperative serum level of over 500ui/ml = bad prognosis
1) abdominal ultrasound - not sensitive or specific but first check
2.1 ) contrast enhanced CT best =
( hypoattenuating homogenous mass with indisticn margins )
if no metastasis and resectable lesion =
endoscopic us ( also detection of small tumors ) for confirmation of resectability = no biopsy needed and immediate surgery
locally advanced in CT
endoscopic us ( also detection of small tumors ) and us guided fine needle aspiraton of pancreatic mass = indicated in patients with chemotherapy or chemoradiation doubtful cases
CT scan showing metastasis
us guided fine needle aspiraton of pancreatic mass = indicated in patients with chemotherapy or chemoradiation
doubtful cases
//////////
us contrast study can als be used
MRI - for mainly metastaisis
preferred for cystic neoplasm
MRCP - preferred for cystic neoplasm and evaluate billary anatomy
what is the staging for pancreatic cancer ?
tis
t1 = tumor limited to the pancreas and less than or equal to 2 cm
t2 = limited to pancrease but more than 2cm
t3= tumor extends but no involvemnt of the celiac axis or superioir mesentric artery
t4 = involved the celiac axis and superioir mesenteric artery = unresectable
what are the resectable procedures ?
surgical resection the only potential curitave treatmnet for pancreatic adenocarcinoma
tumors in head = whipple procedure = pancreatoduodenoectomy
the gallbladder and the bile duct
disection of the right hemicircumferance superioir mesenteric artery to the right of the celiac trunk is recommended
tumors in body and tail - radical anterograde modular pancreatosplenoctomy
dissection of the left hemi circumference of the superioir mesenteric artery to the left of the celia trum
what is the treatmnet for locally advanced pancreatic cancer ?
6 months gemcitabine
90 percent most common pancreatic cancer ?
ductal adenocarcinoma
then
serous or mucinous cystic neoplasm
what is the treatment for borderline resectable pancreatic cancer
full-dose radiotherapy paired either with capecitabine, 5-FU
or reduced doses of gemcitabine
FOLFIRINOX
check again for resectability
resect plus adjuvanttherapy =both 5-FU/folinic acid and gemcitabine
if not resectable continue with chemotherapy
what is the treatmnet in advanced metastatic disease ?
relief of billary obstruction
ERCP plastic stent
surgical hepatojejunostomy
duodenal obstruction
endoscopic expandal metal stent
surgical gastrojejunostomy
pain control
analgesics
pancreatic anzymes
celiac plexus block through endoscopic ultrasound guidance
palliative chemotherapy =
perfomance status 0-1 and no hyperbilirubinemia
gemcitabine / FOLFIRINOX for perfomance
Good candidates are cases with cancer related to BRCA1/BRCA2 mutations
Gemcitabine + nab-paclitaxel: for selected patients with PS 0-2, light comorbidities
gemcitabine monotherapy if peformnce status 2
and bilirubin level more than 1.5 of ULN
