Upper GI Oncology - Pancreas

Question 1

Where is the pancreas located?

Answer 1

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)

Question 2

What are surronding organs of the pancreas?

Answer 2

Duodenum
Jejunum
Stomach
Major vessels IVC
Spleen 
Kidney

Question 3

What are the major lymph nodes of the stomach?

Answer 3

superior and inferior pancreaticoduodenal nodes,

porta hepatis,
suprapancreatic nodes, and para-aortic nodes.

Tail of pancreas tumours drain to splenic hilar nodes.

Question 4

What are the 2 functions of the pancreas?

Answer 4

Exocrine function and Endocrine Function

Question 5

What is the Exocrine function?

Answer 5

Adding digestive juices and enzymes to partially digested food via small ducts - duodenum

produces amylase enzyme to break down carbohydrates

Question 6

What is the Endocrine function?

Answer 6

produces hormones insulin and glucagon, help control amount of sugar in blood stream (blood sugar levels)

Question 7

What is the incidence of pancreatic cancer?

Answer 7

790 000 new cases annually worldwide

In Australia M:F 1406:1254

Incidence increases with age

Higher incidence in urban and socioeconomically disadvantaged populations

Question 8

What are common symptoms/ signs of pancreatic cancer (HEAD, NECK, ULCINATE PROCESS)

Answer 8

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

Question 9

What are common symptoms/ signs of pancreatic cancer (body and tail)

Answer 9

severe back pain

weightloss
pancreatic cancer most frequently occurs in the head and neck of pancreas

Question 10

What are causes of pancreatic cancer?

Answer 10

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

Question 11

How does the cancer spread

Answer 11

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

Question 12

What is the pathology of most pancreatic cancers?

Answer 12

80% Adenocarcinoma arising from the DUCTAL epithelium

Others: islet cell tumours, acinar cell carcinmoa and cystadenocarcinomas

Question 13

Location of most cancers in the pancreas?

Answer 13

60% in head
25% in body& tail
15% in tail alone

Question 14

How is pancreatic cancer commonly graded?

Answer 14

Staging TNM

Grading: more than 50% of people diagnosed with pancreatic cancer have distant mets

Question 15

How do you treat pancreatic cancer?

Answer 15

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)

Question 16

Describe the whipple procedure

Answer 16

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

Question 17

What chemo agent is prescribed?

Answer 17

gemcitabine anf 5 fluro-uracil (5-FU)

Question 18

What are palliative therapies for managing chemo?

Answer 18

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)

Question 19

What does the CTV include for most pancreatic cancer treatments

Answer 19

Primary tumour

Adjacent nodal group (suprapancreatic, coeliac axis & pancreaticodudoenal)

Duodenal wall for head of pancreas tumour

Question 20

What is the superior and inferior extent of the CTV?

Answer 20

SUP: cover coeliac axis – 1.5-2 cm margin

INF: include superior mesenteric lymph nodes

Question 21

What is the posterior margin of the CTV

Answer 21

extend 1.5 cm beyond ANT margin- vertebral body (ensure splanchnic nerves and plexus are included)

Question 22

What is the ANTERIOR margin of the CTV

Answer 22

Extend 1.5 -2 cm from GTV

Question 23

Why are PTV/CTV margins important for pancreatic cancer?

Answer 23

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

Question 24

What are common PRESSCRIPTIONS?

Answer 24

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

Question 25

What are ACUTE common side effects of treatment?

Answer 25

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.

Question 26

What are LATE/LONG TERM common side effects of treatment?

Answer 26

renal failure - may be due to improper shielding (although rare).