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Pancreatic Cancer
 

Pancreatic Cancer

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Presentation by Dr. Aziz Ahmad, Surgical Oncology, Mills-Peninsula Medical Center, April 23, 2011.

Presentation by Dr. Aziz Ahmad, Surgical Oncology, Mills-Peninsula Medical Center, April 23, 2011.

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    Pancreatic Cancer Pancreatic Cancer Presentation Transcript

    • Pancreatic Cancer
      Aziz Ahmad, MD
      Surgical Oncology
      Mills-Peninsula Hospital
      April 23, 2011
    • Statistics
      10th most common cancer
      4th leading cause of cancer death
    • Statistics
      80% of cases are adenocarcinomas from exocrine pancreas
      Less common exocrine tumors include:
      IPMN
      Mucinouscystadenocarcimomas
      Islet cell tumors
      Insulin, glucagon, VIP, sandostatin, gastrin, nonsecreting
      Most common in black males
      Median age of diagnosis is 70
    • Statistics
      Risk Factors:
      Smoking
      Low Vegtables & Fruits
      High red meat
      High sugar sweetened drinks
      Chronic pancreatitis (especially hereditary)
      Diabetes
      Obesity
      Genetic (5-10%)
      Family history, Puetz-Jerghers, HNPCC, FAP, Ataxia-Telangiectasia, Hereditary Pancreatitis, FAMMM-PC
    • Presentation
      Nonspecific symptoms
      Tumors of body and tail (25%)
      Pain and weight loss
      Tumors of the Head (75%)
      Jaundice, steatohrrea, weight loss, Couvoirsier’s sign, pain
      Labs
      Increased LFTs, elevated CA19-9
    • Imaging
      Ultrasound
      Bile duct distension
      Mass
      CT scan with IV contrast
      Quality of imaging continues to improve
      Triple phase CT (pancreas protocol) 90% accurate at finding lesions
      Endoscopic ultrasound
      Help find lesions not seen on CT
      Help determine resectability
      Excellent way to get biopsy
      ERCP
      Therapeutic as well as diagnostic
    • Treatment
      Needs to be multimodal
      Primary care, radiology, gastroenterology, surgery, & oncology
      Surgery is the only cure
      Cure only in those with complete resections
      Otherwise outcome is poor with surgery
    • Treatment
      Finding lesions early (hardest job)
      High index of suspicion by primary care
      Modern CT technology
      Gastroenterologist with specialized skill in ERCP and EUS
      Surgeons with experience in pancreatic surgery
      Radiation/medical oncology up to date with standard of care and knowledge of any promising clinical trials
    • What is resectable?
      Tumors localized to pancreas
      15-20% of patients
      Locally advanced disease in patients with vascular involvement of less than 50% of portal vein
      Or lymph node spread that is limited
      10-15%
      Resection contraindicated in patients:
      >50% involvement of portal vein
      Invasion or encasement of SMA (or hepatic artery)
    • Non Surgical Candidates
      Palliative chemoradiation
      Clinical trials
      Median survival is about 8 months
      Palliative endoscopic or surgical procedures
      5-10% locally advanced patients not initially surgical candidates can be downstaged
    • General Survival Data
      Overall prognosis seems dismal
      70-80% of patients present as inoperable due to metastatic disease or locally advanced disease
      Median survival only 4-6 months
      20-30% are operable with localized or resectable locally advanced disease
      Successful operation can give five year survivals from 20-30%
    • Surgical Procedures
      Tumors of the Body and Tail
      Laparoscopic distal pancreatectomy
      Removal of body & tail of pancreas
      spleen
    • Surgical Procedures
      Head of the pancreas: Whipple Procedure
      Removal of:
      Distal stomach
      Duodenum and proximal jejunem
      Head of pancreas
      Gallbladder and common bile duct
    • Complications
      Whipple Procedure
      bleeding
      Gastroparesis
      Pancreatic duct leak
      Bile duct leak
      Diabetes
      malabsorption
      Distal pancreatectomy
      Bleeding
      Pancreatic duct leak
      Malabsorption
      diabetes
    • Complications
      Particularly Whipple procedure thought to have poor surgical outcomes
      Mills-Peninsula experience in the last 40 Whipples:
      5% 60 day mortality
      Even in patients that recur after 2-3 years, quality of life is excellent before symptoms of disease return
    • Adjuvant Treatment
      Most patients go on to get adjuvant treatment
      Gemcitibine based chemotherapy
      Radiation to the surgical bed
      Even with this 70-80% of patients recur
    • Why Does it Recur?
      Pancreas with rich vascular and lymphatic supply
      Early lymph node spread
      Microscopic at the time of surgery
      Currently best chemo with only 25-30% response rate
    • Conclusion
      So at this time the best answer is to catch the disease early
      In those that you can detect disease early, all hope is not lost
      With an operation, you not only give a chance for cure, but you give hope