Pancreatic Cancer L. Okolicsanyi G. Morana

Pancreas Cancer l 2nd most common GI malignancy l 30,000 cases per year in US l 25,000 deaths per year l 4 th leading cause of death in both men and women l Incidence slowly rising l M>F (1.3:1) l Rare before 45 yrs

Pancreas Cancer Etiology l Diabetes mellitus l Diet: Nitrosamines, Animal fat l Cigarettes l Hereditary predisposition (Hereditary pancreatitis) l Family cancer syndromes (e.g., Peutz-Jeghers, Von Hippel-Lindau, Gardner’s) l Benign disease: Chronic pancreatitis, Intraductal papillary mucinous neoplasms

Normal Pancreas

Pancreatic Tumors l Epithelial –Ductal epithelium (adenocarcinoma and others) –Cystic neoplasms, serous or mucinous l Endocrine –Islet cell tumors, carcinoid tumors l Exocrine –Acinar cell carcinoma l Mesenchymal-Rare

Risk Factors for Pancreatic Cancer

GenePancreatic Cancer (%) Colorectal Cancer (%) p16950 K-ras9050 p DPC45515 BRCA27? Relevance of Genetic Mutations in Pancreatic Cancer

Pancreas Cancer Clinical Features l Weight loss l Head: –Painless jaundice –Gastric outlet obstruction l Body & Tail –Pain –Diabetes mellitus without family history l Metastasis: Hepatomegaly, ascites, Virchow’s (left supraclavicular) node, Trousseau’s syndrome (migratory superficial thrombophlebitis)

Pancreas Cancer Courvoisier’s law “In the presence of jaundice a palpable gall bladder is unlikely to be due to stone”

Pancreas Cancer Investigations l Laboratory tests: –LFT’s –CA 19-9 l Radiologic tests: –Ultrasound –CT scan + biopsy –ERCP + biopsy –EUS + biopsy

Algorithm for diagnosis and staging of Pancreatic Cancer FNAC

Pancreas Cancer Treatment l Curative: –Resection if possible –Unresectable if metastasis or major vessel involvement –Whipple procedure for head (radical pancreatoduodenectomy) –Distal pancreatectomy for body & tail l Palliative: –Bypass –Stent

Actuarial Survival after Pancreatico- duodenectomy

Pancreas Cancer Survival at 5 yrs l Head of Pancreas5-15% l Body & Tail of pancreas2% l Distal CBD15-35% l Ampulla30-65% l Mild improvement with adjuvant therapy

Pancreas Cancer