Pancreatic cancer Flashcards
function of pancreas
-excretes enzymes to break down fats , carbs , protein, and nucleic acid in food
-secretes insulin and glucagon to control blood sugar levels
Types of Pancreatic Cancer:
most common
ductal adenocarcinoma 80-90%
Prognosis
carries a high mortality rate
1 year survival=24%
5 year survival=9%
Aetiology
-smoking- 20% of cancer
-hereditary-10% (genetic predisposition or inherited cancer syndromes)
-chronic pancreatitis
-genetic disorders associated with the BRCA1, BRCA2, PALB2, and ATM genes
-obesity
signs and symptoms
-early stages is usually asymptomatic
-80% of patients are diagnosed at late stages
signs and symptoms: early onset symptoms
-abdominal pain
-bloating
-flatulence
-vomiting
-change in bowel habits (constip or dia)
signs and symptoms: late onset symptoms
-abdominal or mid back pain
-obstructive jaudince (caused by compression of distal common bile duct)
-weight loss
-dark urine or light colour stool
Diagnostic Workup: Imaging used to
-define anatomy- is there a mass and what is the extent
-determine pathology -fine needle aspiration by EUS or CT
-dictate management- is the cancer restectable
indications of imaging modalities used to investigate pancreatic tumours:
-US
-CT
-MRI
-ENDOSCOPIC ULTRASOUND
-primary investigation for jaundice and epigastric pain
-investigation of choice for when pancreatic cancer is suspected
-used when CT findings are inconclusive
-problem solver. Most useful when there is a biliary obstruction w no definite mass in CT or MRI
what is biomarkers
looks for genes , proteins and other substances that gives info about the cancer
Biomarkers for Differential Diagnosis:
CA-19 features
-NOT FOR screening
-poor predictive value for cancer
-CA-19 value will still be normal w patients in early stage
-when elevated indicates advanced stage cancer
-may be more useful in surveillance
stage IA & IB
purely based on size of tumour
T1= less than or 2cm
T2=inbetween 2 and 4cm
Stage IIA
T3 ( greater than 4cm) but N= -ve
Stage IIA
T1,T2 or T3
N1
stage IIB
T1, T2 or T3
N1 = Stage IIB disease
stage III
Irrespective of T status,
N2 = Stage III OR T4, any N
cancer is 4 or more lymph nodes
Stage IV
Irrespective of T and N status,
M +ve
Treatment Options
- resectable = neo or adj RT
-locally adv or unresectable= palli or neo(surgery after)
-metastatic= palli
An MDT approach is imperative…
-onc
-surgeon
-radiologist
-gastroenterologist
-RO
-pathologist
-social worker
-dietician
Contraindications for resection include:
-liver, lung and peritoneal mets
-distant LN
-aortic invasion or encasement
-major encasement of SMA,SMV, ceolic or hepatic arteries
At time of diagnosis
-20% have resectable tumour
-30% locally advanced tumour that is unresectable
-50% have metastatic disease
tx options for resectable or borderline resectable
-neo therapy
-surgery
-postoperative chemo
-postoperative chemoRT
tx options for locally advanced pancreatic cancer
-chemo w or w/o targeted therapy
-chemoRT
-surgery
-palli surgery
tx options for metastic or recurrent pancreatic cancer
-chemo w or w/o targeted therapy
Neoadjuvant Treatments:Key messages for
-locally advanced stage disease
-borderline resectable disease
-resectable disease
-yes as it may enable surgical resection
-important role
-more evidence needed
however in 2023, No impact on OS or DFS; however,
improved the chance of R0 resectability
Surgical Management: Stage I and II
-surgical resection
-distal pracreatectomy with splenectomy
-pancreaticduodenectomy “whipple procedure”
surgical resection
-total pancreatectomy doesnt improve survival compared to partial resection
-distal pracreatectomy with splenectomy
used for body and tail cancers
-pancreaticduodenectomy “whipple procedure”
used for cancers in head of pancreas
-pancreaticduodenectomy “whipple procedure”
used for cancers at the head of pancreas
Adjuvant Treatments for Stage I and II:
for who
when
-For surgical patients with curative intent
-Within 12 weeks post surgery; typically adjuvant chemo
-Approx how many of patients don’t go on to receive the intended adjuvant treatments?
-why?
«25%
«-surgical complications
-poor performance status and co-morbidities
-patient refusal
-disease relapse
Adjuvant Treatments for Stage I and II:
The role of chemotherapy as per NCI 2022
-for patient w good PS: adjuvant FOLFIRINOX or combination of gemcitabine and capecitabine
-for older patients or patients w poorer PS: adjuvant gemcitabine or 5FU as a single agent therapy
