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
