Pancreatic cancer Flashcards
General findings
Pancreatic cancer is the fourth leading cause of cancer deaths in the US and typically affects older individuals in the sixth to eighth decades of life. Underlying risk factors include smoking, obesity, heavy alcohol consumption, and chronic pancreatitis. Pancreatic carcinomas are mostly ductal adenocarcinomas and frequently located in the pancreatic head. The disease is commonly diagnosed at an advanced stage because of the late onset of clinical features (e.g., epigastric pain, painless jaundice, and weight loss). In many cases, the tumor has already spread to other organs (mainly the liver) when it is diagnosed. Treatment is often palliative as surgical resection is only possible in approx. 15% of cases. The most commonly used surgical technique is the pancreaticoduodenectomy (“Whipple procedure”). Five-year survival rates range from 1–20% depending on the extent, spread, and resectability of the tumor.
Risk factors
- Smoking ✔
- Chronic pancreatitis ✔
- High alcohol consumption ✔
- Type 2 diabetes
- Obesity
- Occupational exposure to chemicals used in the dry cleaning and metal working industries
- Cirrhosis of the liver✔
- H. pylori infection; excess stomach acid ✔
Inherited genetic syndromes (10% of pancreatic cancers)
- Familial pancreatic carcinoma
- Hereditary pancreatitis (mutations in the PRSS1 gene)
- Peutz-Jeghers syndrome✔
- Familial atypical multiple mole melanoma (FAMMM) syndrome
- Hereditary breast and ovarian cancer syndrome (BRCA1 and BRCA2 mutations)
- Von-Hippel-Lindau syndrome
- Neurofibromatosis type 1
- Multiple endocrine neoplasia type 1
Clinica
Often no early signs present!!💥
Il primo sintomo più frequente è un ittero non associato a dolore da colica della colecisti. Questo quando il tumore è situato alla testa del pancreas.
The symptoms of pancreatic cancer may be similar to those of chronic pancreatitis. Differential diagnosis is difficult since carcinoma may be accompanied by pancreatitis!✔
1.Belt-shaped epigastric pain which may radiate to the back
2.Jaundice
-Courvoisier sign: enlarged gallbladder and painless
jaundice (painless jaundice ,a nontender gallbladder,
is the most common initial symptom of pancreatic
cancer but usually doesn’t occur when the primary
tumor is located in the tail or body of the pancreas.
Painless jaundice may also occur in
cholangiocarcinoma. Gallstones, on the other hand,
cause obstructive jaundice with a painful gallbladder!
-Pale stools, dark urine, and pruritus (segni di iperbilirubinemia diretta-coniugata)
- Weight loss, nausea, weakness, poor appetite
- Diarrhea (possibly steatorrhea secondary to exocrine pancreatic insufficiency)
- Superficial thrombophlebitis (in 10% of cases, also called Trousseau syndrome or thrombophlebitis migrans)
- Recurring thrombophlebitis in various locations
- Classically associated with pancreatic cancer
- Thrombosis (e.g., phlebothrombosis, splenic vein thrombosis)
- Impaired glucose tolerance (rarely)
LAB
1.Tumor markers: CA 19-9 and CEA
Used to monitor the progression of cancer and
treatment efficacy
2.Possibly ↑ lipase
Imaging
1.First test: usually either contrast-enhanced abdominal CT or ultrasound → if ultrasound reveals a pancreatic mass → subsequent CT
NB Patients that present with jaundice as the initial symptom usually undergo an ultrasound examination. If abdominal pain and weight loss are the initial presenting symptoms, a CT scan is preferred.
- Poorly defined, hypodense/hypoechoic and hypovascular mass
- Double-duct sign : With increasing size, tumors of the pancreatic head may block bile drainage in both the common bile duct and the pancreatic duct, leading to dilatation of both structures.
2. Endoscopic or magnetic retrograde cholangiopancreatography (ERCP/MRCP): to rule out choledocholithiasis and/or if biliary decompression is indicated, e.g., in case of palliative treatment to alleviate jaundice
- Endoscopic ultrasound (EUS)
- Used when other diagnostic tests are inconclusive or to perform fine needle aspiration
- Findings similar to transcutaneous ultrasound
4.Fine needle aspiration
Not routinely performed
Can help differentiate pancreatic cancer from pancreatitis (e.g., chronic or autoimmune)
Can be done via EUS (preferred) or percutaneously (US or CT-guided)
Caratteristiche
1.Location
Pancreatic head: 75% of cases
Pancreatic body: 15–20% of cases
Pancreatic tail: 5–10% of cases
2.Pancreatic exocrine tumors (95%)
Mostly ductal adenocarcinoma
Less common: acinar adenocarcinoma (acinar cells produce digestive enzymes) and others
3.Pancreatic endocrine tumors (neuroendocrine tumors/NET, < 5% of tumors)
Insulinomas (result in hypoglycemia)
Gastrinomas
Vasoactive intestinal peptide-producing tumors (VIPomas), pancreatic polypeptide-secreting endocrine tumors of the pancreas, glucagonomas, somatostatinomas
Ddx
1.Pancreatitis
2.Metastasis (e.g., breast carcinoma, bronchial carcinoma)
3.Pancreatic pseudocyst
4.Pancreatic cyst: Epithelium-lined cyst, filled with serous or mucous liquid, often associated with the rare von-Hippel-Lindau syndrome; can be benign, precancerous or cancerous!🧨
Clinical features: abdominal pain, back pain, jaundice!, and in case of infection, fever and sepsis
CT scan: cyst appears as a well-circumscribed hyperdense mass in comparison to the surrounding tissue. Pancreatic cancer, on the other hand, is hypodense.
ERCP: cyst shows contrast-enhancement
Treatment
Asymptomatic cyst: no surgical treatment
Symptomatic cyst: CT-guided, endoscopic, or surgical drainage
Treatment
As the only curative treatment option for pancreatic cancer is surgical resection, patients with operable tumors (∼ 20%) are always recommended for surgery. If surgical tumor resection is not possible or distant metastasis is present, a palliative approach is chosen.
Pancreatic head carcinoma
Whipple procedure
- Resection of pancreatic head, distal stomach, duodenum, gallbladder, and common bile duct
- Lymphadenectomy
- Reconstruction by enteroenterostomy or Roux-en-Y anastomosis
- Pylorus-preserving pancreaticoduodenectomy (Traverso-Longmire procedure): a modification of the Whipple procedure that preserves the gastric antrum, the pylorus and a small part of the duodenum (anastomosed to the jejunum) to provide a more physiologic stomach emptying
Pancreatic body and tail carcinoma
!Resection of the left side of the pancreas with splenectomy.
In some cases, duodenopancreatectomy with splenectomy
Indicated in a curative treatment approach if partial removal of the pancreas is insufficient
Neoadjuvant or adjuvant chemoradiotherapy
- To reduce tumor size, improve symptoms, and prolong life
- Chemotherapy or radiation therapy without surgery cannot cure the patient.
Palliative approach
Treating cholestasis significantly increases the patient’s quality of life because of a reduction in itching which usually cannot be achieved by drug management.
1.Cholestasis : ERCP with stent implantation!
-Percutaneous transhepatic bile duct drainage (PTCD)
Indication: if endoscopic access path is complicated (e.g., in duodenal stenosis, duodenal resection, and inaccessibility of the biliodigestive anastomosis)
2.Gastroenterostomy: best supportive care in patients with gastric outlet stenosis. The stomach is anastomosed with the small intestine bypassing the duodenum.
Percutaneous endoscopic gastrostomy (PEG) tube as a relief tube: indicated for severe palliative patients with chronic ileus and subileus that are inoperable
Complications
- Lymphogenic and hematogenous metastasis
- Early stage: nearby lymph nodes and liver
- Advanced stage: surrounding visceral organs (duodenum, stomach, colon) and lungs - Stenosis
- Gastric outlet stenosis
- Stenosis of the common bile duct (cholestasis)
Other complications
Secondary diabetes mellitus
Disseminated intravascular coagulation (DIC)
Necrolytic migratory erythema
DOMANDA Paziente con storia di modesto dolore addominale che esegue ecografia addominale: nel caso di riscontro incidentale di una formazione cistica pancreatica, quale consiglieresti come esame di secondo livello?
Ecografia con mdc
TC addome senza mdc
TC addome con mdc
✔RM addome
Nessuno, non è necessario alcun approfondimento diagnostico
In caso di riscontro di una lesione pancreatica cistica (ipo/anecogena all’ecografia), l’esame più indicato per la sua caratterizzazione è la risonanza magnetica, che permette di valutare i rapporti contratti con i dotti pancreatici principale e secondari, la localizzazione e la struttura interna.
