Pancreatic Cancer FRCR CO2A Flashcards
what’s the peak incidence for pancreatic cancer?
- male eighth decade
- female ninth decade
what subsite of pancreas is frequently affected by pancreatic cancer?
Head 80%
What are RF for pancreatic cancer?
- 3% inherited
- Cigarette smoking, doubles the risk
- Diet rich in protein and carbs and poor in fruit and Vegetables
- toxins like 2-naphthylamine, benzidine and DDT
- long standing DM I and II
- Chronic pancreatitis
- obesity
- Total Gastrectomy (2 to 5 x)
What’s the MC pathology of pancreatic cancer?
Ductal Adenocarcinoma (90%)
others: acinar, anaplastic, cysadenocarcinoma, sq cell, sarcoma
NEUROENDOCRINE Tumors
Where does pancreas lie in human body?
Retroperitoneal Structure, infront of 1st and 2nd Lumbar vertebrae
How many parts pancreas have?
4
Head, Neck, Body and Tail
where does pancreatic duct open?
pancratic duct combines with CBD and opens in the ampulla of vater
what’s the lymphatic drainage of pancreas?
- pancreaticoduodenal
- suprapancreatic
- pyloric
- pancreaticosplenic nodes
Drain into Coeliac and superior Mesenteric nodes
what causes severe pain in pancreatic cancer?
involvement of 1st and 2nd Coeliac ganglia, leading to back pain
what structures involvement leads to inoperable pancreatic cancer?
Vessels like SM Vessels, portal vein, splenic vein, Celiac artery and its branches
what’s the typical s/s of pancreatic cancer?
sudden onset painless jaundice
what are S/S of pancreatic cancer?
- GOO (duodenal spread)
- Obst Jaundice
- Cholangitis
- Steatorrhoea
- Back pain
what are s/s of metastatic pancreatic cancer?
- Jaundice (extensive liver mets)
- abdominal pain and ascites
- Blumer’s shelf
- SOB (Pulm mets), always exclude PE
- Virchow’s node
what is blumer’s shelf?
peritoneal metastasis in Pouch of Douglas, which can be palpated rectally
what is virchow’s node
malignant left Supraclavicular node
What paraneoplastic syndromes are a/w pancreatic cancer?
- migratory thrombophlebitis (Trousseau’s sign)
- Weber Christian (Subcut fat necrosis, polyarthralgia, eosinophilia)
- dermatomyositis/polymyositis
what are constitutional symptoms of pancreatic cancer?
- fatigue
- wt loss
- anorexia
- Venous TE
what blood tests are advised in pancreatic cancer?
CBC/LFT/KFT/Coagulation profile
CA 19.9
what imaging is advised for pancreatic cancer?
Dual phase helical CT scan
Arterial phase: show the pancreas
Venous phase: look for liver mets
ERCP useful in obstructive jaundice: endobiliary stent placement, brushings
EUS
How is EUS useful in pancreatic cancer?
- to assess vascular involvement
- obtaining a biopsy, especially in pts with a small tumor in whom standard US or CT guided biopsy may be difficult
is tissue proof necessary before starting Rx for pancreatic cancer? and if yes why?
yes, radiologically difficulty to distinguish between chronic pancreatitis from carcinoma and CA 19-9 may be elevated in obstructive jaundice
sometimes diagnosis like NET could be missed
what is Rx of resectable pancreatic cancer?
Radical surgery followed by chemotherapy
role of post op crt in pancreatic cancer
controversial, practised in USA
Goal of surgery in localized pancreatic cancer
negative margin
what surgery in done for pancreatic cancer?
Pancreatico-Duodenectomy (whipples’) or pylorus preserving Pancreatico duodenectomy for Head, Neck and uncinate process
what Sx is done for pancreatic cancer in tail and body of pancreas?
distal pancreatectomy
what’s morbidity and mortality rate of whipples at high volume centre?
morbidity: 40%
mortality: 2.4%
Complications of whipple’s surgery
- delayed gastric emptying
- pancreatic fistula
- sepsis
- H’ge
- malabsorption
- diabetes mellitus
What’s standard adjuvant treatment for pancreatic cancer?
mFOLFIRINOX
GemCap
what’s the role of post op CRT in pancreatic cancer?
GERCOR, failed to demonstrate benefit
what are borderline resectable tumors?
- u/l or b/l SMV or Portal vein infringement
- < 50% abutment of circumference of SMA
- abutment/encasement of hepatic artery or short segment occulusion of SMV
what’s the status of NACT or NACRT for pancreatic cancer in UK?
not used currently
How is LA pancreatic cancer treated?
High risk of micro metastatic disease, porgression occurs in 30 to 40 % of pts in fisrt 3 to 4 months,
so Chemotherapy is preferred over CRT.
chemotherapy regimens for LAPC? NCCN 2025
FOLFIRINOX or modified
FOLFIRINOX
* Gemcitabine + albuminbound paclitaxeld
* Liposomal irinotecan
+ 5-FU + leucovorin +
oxaliplatin (NALIRIFOX)
Acceptable Rx option for LAPC:
Induction chemo for 3 to 4 cycles followed by consolidation CRT (50.4 to 54 Gy/ 28/30#) with capecitabine @ 830 mg/m2 BD on Rx days
Regimens for metastatic pancreatic cancer?
FOLFIRINOX (category 1) or
modified FOLFIRINOX
* Gemcitabine + albumin-bound
paclitaxel (category 1)
* NALIRIFOX
S/Es of FOLFIRINOX?
Grade 3/4 toxicity including neutropenia 45.7%
fatigue 23%
diarrhoea 12.7%
neuropathy 9%
2nd L chemo for metastatic pancreatic cancer
OFF (oxaliplatin, folinic. acid and 5 FU)
CAPEOX
Gem Erlotinib
How is ITV generated ?
combining GTV outlines from multiple phases of respiration
atleast 3 phases, end inspiration, end expiration, and time weighted average or conventional 3D scan
What’s RT dose is given for pancreatic cancer?
50 . 4 Gy/ 28#
what SBRT dose is given in pancreatic cancer
40 Gy/ 5#
