Pancreatic Cancer

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Pancreatic Cancer

• Andrew Avery
• A.M. Report
• 04/29/09

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Epidemiology

• Incidence has been increasing since the 1930s
• 4th leading cause of cancer death in U.S. men and
  women
• Approximately 33,730 new cases were anticipated
  in 2006, with 32,300 expected deaths
• Age-adjusted incidence rates were approximately
  30 percent higher in men and 50 percent higher in
  blacks compared with other races

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Acquired Risk Factors

• Established Smoking (RR 2.5), Obesity, and
  Chronic Pancreatitis.
• Possible DMII, High intake of Fat and/or Meat
  (particularly smoked or processed meats),
  Hepatitis B, Helicobacter Pylori infection, and
  h/o Partial gastrectomy or cholecystectomy

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Hereditary Risk Factors

• Genetic susceptibility may play a role in 5-10
  of cases
• Hereditary Chronic Pancreatitis 2/2 cationic
  trypsinogen gene that is transmitted as an
  autosomal dominant trait with high penetrance
• Familial Cancer Syndromes and gene mutations with
  inc. risk Peutz-Jeghers (LKB1), Familial
  Atypical MM Syndrome (p16), ataxia-telangiectasia
  (ATM) and possibly familial adenomatous polyposis
  and BRCA2

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Pathology

• 95 of malignant pancreatic neoplasms arise from
  exocrine (ductal or acinar) cells
• 60 arise in head, 15 in body, 5 in tail in
  20 the tumor diffusely involves the entire gland

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Clinical Manifestations

• The initial presentation varies according to
  tumor location, but most pts experience pain,
  weight loss, or jaundice.
• Pain in 80-85 of patients with locally advanced
  or advanced disease. Usually felt in the upper
  abdomen as a dull ache that radiates straight
  through to the back.
• Weight Loss May be profound and may be
  associated with anorexia, early satiety,
  diarrhea, or steatorrhea.

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Clinical Manifestations

• Jaundice Often accompanied by pruritus, acholic
  stools, and dark urine
• Tumors in the pancreatic body or tail usually
  present with pain and weight loss, while those in
  the head of the gland typically present with
  steatorrhea, weight loss, and jaundice.
• New-onset atypical DM, Unexplained Malabsorption,
  Unexplained Pancreatitis, or Migratory
  Thrombophlebitis (Trosseaus Sign) may be seen

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Physical Findings

• Abdominal Mass or Ascites present in 20 on
  presentation
• Nontender, Palpable Gallbladder (Courvosiers
  Sign) may be seen or felt at the right costal
  margin in those with jaundice
• Left Supraclavicular Lymphadenopathy (Virchow's
  node) or a Palpable Rectal Shelf are present in
  some patients with widespread disease
• Hepatomegaly and rarely, Subcutaneous Areas of
  Nodular Fat Necrosis (Pancreatic Panniculitis)
  may be evident

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Differential Diagnosis

• Chronic Pancreatitis
• Pancreatic Endocrine Tumors
• Autoimmune Pancreatitis
• Lymphoma
• Variety of other rarer conditions

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Diagnostic Studies

• The dx of pancreatic cancer is typically made
  radiographically and histologically
• Serum Studies
• -Routine laboratory testing may reveal an
  elevated serum bilirubin concentration or
  alkaline phosphatase activity mild anemia may be
  present
• -Serum tumor marker CA 19-9 is not recommended
  as a screening test as those with a
  Lewis-negative phenotype (an estimated 5 to 10
  percent of the population) are unable to
  synthesize. Degree of elevation at diagnosis and
  at post-op is useful for long-term prognosis.
  Also useful to follow dz post-op

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Imaging Studies

• Abdominal US Dilated bile ducts or the presence
  of a mass in the head of the pancreas suggest a
  pancreatic tumor
• Helical CT w/ angiography Useful in pts who are
  not jaundiced and for those in whom intestinal
  gas interferes with US. Unlike US, can be used
  for staging
• If no mass lesion seen, then ERCP, EUS, or
  MRI/MRCP may reveal a mass or malignant ductal
  structures

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CT angiogram of cancer in the head of the pancreas
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ERCP in Pancreatic Cancer showing Double Duct
Sign
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FNA Biopsy

• Preoperative biopsy of a pancreatic mass can be
  accomplished either percutaneously (w/ either US
  or CT guidance) via EUS or ERCP
• Percutaneous A theoretical concern exists that
  tumor cells may disseminate intraperitoneally or
  along the needle path in pts believed to be
  candidates for potentially curative resection
• ERCP Sens. is probably lower than EUS
• EUS Method of choice, particularly in potential
  surgical candidates

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Need for Pre-op Biopsy

• Diagnostic bx of a suspected pancreatic
  malignancy is indicated for treatment planning if
  there is systemic spread of disease, local
  evidence of unresectability, or if the patient is
  unfit for surgery
• However, it is controversial whether a pre-op
  diagnostic bx is needed in a fit patient with a
  potentially resectable pancreatic lesion
  suspected of malignancy. While a positive bx can
  confirm the suspected diagnosis, a benign sample
  does not exclude the presence of malignancy
• In one systematic review of 53 studies addressing
  this issue, the negative predictive value of
  percutaneous and EUS-guided bxs was only 60 to
  70
• Thus, many surgeons proceed directly to surgery
  if the patient is a reasonable operative
  candidate

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FNA of Pancreatic Cancer
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Clinical Staging and Prognosis of Pancreatic
Adenocarcinoma
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Treatment

• Resectable surgery /- adjuvant therapy
• -surgery Pancreaticoduodenectomy (Whipple)
• -adjuvant inc survival w/ chemorad(eg post-op
  5-FU gemcitabine)
• Locally Advanced 5-FU chemorad inc survial when
  c/w chemo or xrt alone ? gemcitabine
• Metastatic gemcitabine inc survival c/w 5-FU.
  Adding erlotinib provides slight additional benef
• Palliative Supporting Care endoscopic stenting
  or surg bypass for obs jaundice or gastric outlet
  obstruct. XRT, opiates and plexus neurolysis for
  pain. Pancreatic enzyme replacement for weight
  loss 2/2 fat malabsorption