Upper GI Oncology - Pancreas Flashcards
Where is the pancreas located?
Pancreas is located retroperitoneally @ L1-L2 level & lies transversely in the upper abdomen
Head in Duodenum, Tail in Spleen hilum
main body located in left upper quadrant - posterior to stomach (near ML), anterior to IVC
(clinically divided into head, body, tail)
What are surronding organs of the pancreas?
Duodenum Jejunum Stomach Major vessels IVC Spleen Kidney
What are the major lymph nodes of the stomach?
superior and inferior pancreaticoduodenal nodes,
porta hepatis,
suprapancreatic nodes, and para-aortic nodes.
Tail of pancreas tumours drain to splenic hilar nodes.
What are the 2 functions of the pancreas?
Exocrine function and Endocrine Function
What is the Exocrine function?
Adding digestive juices and enzymes to partially digested food via small ducts - duodenum
produces amylase enzyme to break down carbohydrates
What is the Endocrine function?
produces hormones insulin and glucagon, help control amount of sugar in blood stream (blood sugar levels)
What is the incidence of pancreatic cancer?
790 000 new cases annually worldwide
In Australia M:F 1406:1254
Incidence increases with age
Higher incidence in urban and socioeconomically disadvantaged populations
What are common symptoms/ signs of pancreatic cancer (HEAD, NECK, ULCINATE PROCESS)
Obstructive jaundice
- due to obstruction of the biliary system
Dark urine - also due to obstruction of the biliray system that results in excess bilirubin excreted in urine
clay coloured stools
abdominal pain
What are common symptoms/ signs of pancreatic cancer (body and tail)
severe back pain
weightloss
pancreatic cancer most frequently occurs in the head and neck of pancreas
What are causes of pancreatic cancer?
Diesease rarely occurs in people younger than 40
Smoking
Occupation- rubber industry or benezidine dye industry
Diabetes Mellitus & chronic pancreatitis
Possible familial trend
Obesity
High fat diet
How does the cancer spread
Local: throughout the pancreas, duodenum, stomach colon
obstructs common bile duct
Blood: via portal vein to liver
Lungs
Invades adjacent structures via lymph nodes
SPREAD TO LUNG AND LIVER MOST COMMON
What is the pathology of most pancreatic cancers?
80% Adenocarcinoma arising from the DUCTAL epithelium
Others: islet cell tumours, acinar cell carcinmoa and cystadenocarcinomas
Location of most cancers in the pancreas?
60% in head
25% in body& tail
15% in tail alone
How is pancreatic cancer commonly graded?
Staging TNM
Grading: more than 50% of people diagnosed with pancreatic cancer have distant mets
How do you treat pancreatic cancer?
Primary resection is the only chance of cure. - Less than 20% of patients have the potential for surgical resection.
pancreaticoduodenectomy - (whipple procedure)
total removal of the pancreas leads to diabetes and lack of exocrine function.
Adjuvant therapy (CHEMO + RT)
Describe the whipple procedure
Pancreaticoduodenectomy
Resection of head of pancreas+ duodenum, distal stomach, gall bladder and common bile duct
High local failure and high mortality (5%)
Long patient recovery
What chemo agent is prescribed?
gemcitabine anf 5 fluro-uracil (5-FU)
What are palliative therapies for managing chemo?
Narcotics - for pain control (severe pain caused by infiltration of coeliac plexus)
coeliac plexus/axis nerve blocks
Biliary stenting - for jaundice
Drainage of ascites- accumulation of fluid in the abdominal region
Pallitaitve chemo
Palliative RT (bone or brain mets)
What does the CTV include for most pancreatic cancer treatments
Primary tumour
Adjacent nodal group (suprapancreatic, coeliac axis & pancreaticodudoenal)
Duodenal wall for head of pancreas tumour
What is the superior and inferior extent of the CTV?
SUP: cover coeliac axis – 1.5-2 cm margin
INF: include superior mesenteric lymph nodes
What is the posterior margin of the CTV
extend 1.5 cm beyond ANT margin- vertebral body (ensure splanchnic nerves and plexus are included)
What is the ANTERIOR margin of the CTV
Extend 1.5 -2 cm from GTV
Why are PTV/CTV margins important for pancreatic cancer?
Pancreas is a retroperiteneal organ moves vertically up to 1.5-2.0cm with respiration (this has to be taken into account in defining the CTV-PTV margin
What are common PRESSCRIPTIONS?
RADICAL: (in combo with chemo) 5 FU – 45-50.4 Gy in 25-28# (1.8 Gy/# 5-5.5 weeks)
or in combo with gemcitabine
PALLIATIVE: 30 Gy in 10#, 3 Gy/# in 2 wks
What are ACUTE common side effects of treatment?
Nausea, diarrhoea and pain may - (Antiemetics and pain relief)
Severe mucositis or even ulceration of the stomach or duodenum may occur. Maintaining adequate nutrition and hydration.
Concomitant chemotherapy - bone marrow suppression.
What are LATE/LONG TERM common side effects of treatment?
renal failure - may be due to improper shielding (although rare).
