Chapter 54: Pancreas- Pancreatic Carcinoma Flashcards
What is it?
Adenocarcinoma of the pancreas arising from duct cells
What are the associated risk factors?
- Smoking 3× risk
- diabetes mellitus
- heavy alcohol use
- chronic pancreatitis
- diet high in fried meats
- previous gastrectomy
What is the average age?
>60 years
What are the different types?
- >80% are duct cell adenocarcinomas
- other types include
- cystadenocarcinoma
- acinar cell carcinoma
What percentage 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
signs/symptoms of 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 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 cancer of the pancreatic
HEAD?
- Weight loss (90%)
- Pain (75%)
- Jaundice (70%)
What is “Courvoisier’s sign”?
Palpable, nontender, distended gallbladder
What is the classic presentation of pancreatic cancer in the head of
the pancreas?
Painless jaundice
What are the associated lab findings?
- 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?
Carbohydrate Antigen 19–9 ie CA-19–9
What diagnostic studies are performed?
- Abdominal CT scan
- U/S
- cholangiography (ERCP to rule out choledocholithiasis and cell brushings)
- endoscopic U/S with biopsy
What is the treatment based on location:
Head of the pancreas?
Whipple procedure (pancreaticoduodenectomy)
What is the treatment based on location:
Body or tail?
Distal resection
What factors signify inoperability?
- 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 mortality rate is associated with a Whipple procedure?
<5% at busy high volume centers
What is the “pylorus-preserving Whipple”?
No antrectomy; anastomose duodenum to jejunum
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
What is the postoperative adjuvant therapy?
Chemotherapy ± XRT
What is the palliative treatment if the tumor is inoperable and biliary
obstruction is present?
Percutaneous transhepatic cholangiography (PTC) or ERCP and placement of stent across obstruction
What is the prognosis at 1 year after diagnosis?
Dismal; 90% of patients die within 1 year of diagnosis
What is the survival rate at 5 years after resection?
20%
