Understanding pancreas cancer, including the causes, symptoms, diagnostic tests and the best treatment options for this very serious malignancy

1. Pancreas Cancer
www.aboutcancer.com

2. Pancreas Cancer
Incidence (2014 Data) Deaths
46,420 (2.8%) 39,590 (6.8%)
The 5 year survival is only 6.7%
Life time risk of developing this
cancer is 1.5%

3. 2014 Statistics
Male Female
New Cases 23,530 (2.7%) 22,890 (2.8%)
Deaths 20,170 (6.5%) 19,420 (7%)

4. Age and Pancreas Cancer
Median age is 71

5. New Cases per 100,000

6. Trends in Incidence and
Survival

7. Stage and Survival - SEER
Stage Incidence Survival/5y
Local 9% 25.8%
Regional 28% 9.9%
Distant 53% 2.3%

8. Risk factors for pancreatic
cancer include the following
- Smoking
- Obesity
- Personal history of diabetes or chronic
pancreatitis
- Family history of pancreatic cancer or
pancreatitis
- Certain hereditary conditions

9. Symptoms
Most patients present with pain (in the back)
weight loss or jaundice
Tumors in the head of the pancreas are more
likely to have jaundice,
Those that arose in the body or tail, more
likely pain and weight loss.

10. Bile: yellowish fluid produced in the liver that aids
in digestion of fat in the small intestine
Liver

11. Bile: passes through the common bile duct through the
head of the pancreas on it’s way to the duodenum
Liver
Hepatic Duct
Common Bile Duct
Duodenum
Pancreatic Duct

12. Bile duct carries the bilirubin through the head of the
pancreas on it’s way to the duodenum
Tail of the Pancreas
Common Bile Duct
Common Bile Duct Body of the Pancreas
Head of the Pancreas

13. Tumors in the head of the pancreas are more likely
to have jaundice
Tail of the Pancreas
Common Bile Duct
Common Bile Duct Body of the Pancreas
Head of the Pancreas
Tumor in the Head of the
Pancreas
Obstruct the Bile Duct

14. Tumors in the head of the pancreas are more likely
to have jaundice
Tail of the Pancreas
Common Bile Duct
Common Bile Duct Body of the Pancreas
Head of the Pancreas
Pancreatic Duct
Tumor in the Head of the
Pancreas

15. Head of the Pancreas Tumor
Blocking the pancreatic duct
and common bile duct
Common bile Duct
Pancreatic
duct
Common
bile
Duct
cancer
Duodenum

16. Tail of the Pancreas
Common Bile Duct
Common Bile Duct Body of the Pancreas
Head of the Pancreas
Tumor
Tumors in the body or tail are more likely to
present with pain or weight loss

17. Symptoms of Pancreas
Cancer
• Asthenia (weakness) – 86 percent
• Weight loss – 85 percent
• Anorexia (no appetite)– 83 percent
• Abdominal pain – 79 percent
• Epigastric pain (stomach) – 71 percent
• Dark urine – 59 percent
• Jaundice – 56 percent
• Nausea – 51 percent
• Back pain – 49 percent
• Diarrhea- 44 percent
• Vomiting – 33 percent
• Steatorrhea (fatty stools)– 25 percent
• Thrombophlebitis – 3 percent

18. Signs of Pancreas Cancer
• Jaundice (yellow) – 55 percent
• Hepatomegaly (large liver) - 39 percent
• Right upper quadrant mass – 15 percent
• Cachexia (wasting) – 13 percent
• Courvoisier’s sign (nontender but palpable
distended gallbladder at the right costal
margin) – 13 percent
• Epigastric mass (fell lump in stomach) – 9
percent
• Ascites (abdominal fluid) – 5 percent

19. Pathology
Ductal adenocarcinoma accounts for about 85% of all
neoplasms. And more than 95% of all pancreatic
cancers arise from the exocrine (digestive enzymes)
elements.
Cancers that arise from the endocrine cells
(neuroendocrine, islet cells) account for 5% or less

20. Parts of the Pancreas
Portal Vein
Aorta
Superior Mesenteric Vein
Head Body Tail

21. Cancer in the Head of the
Pancreas
Head
Tail
Body

22. Location of Pancreas Cancer
• 60 to 70 percent of exocrine pancreatic cancers
are localized to the head
• 20 to 25 percent are in the body/tail and
• the remainder involve the whole organ
H = Head
N = Neck
B = Body
T = Tail
Un = Uncinate

23. Location of Pancreas Cancer
• 60 to 70 percent of exocrine pancreatic cancers
are localized to the head
• 20 to 25 percent are in the body/tail and
• the remainder involve the whole organ
H = Head
N = Neck
B = Body
T = Tail
Un = Uncinate

24. Tests used to evaluate and stage
pancreas cancer
• Routine blood tests e.g. liver products
like bilirubin
• Elevated tumor markers (CA 19-9 or
CEA)
• MRI, CT scans, Ultrasound
• Endoscopy including endoscopic
ultrasound or ERCP
• Laparoscopy
• Biopsy

25. CA 19-9
The reported sensitivity and specificity rates of CA 19-9 for pancreatic
cancer range from 70 to 92, and 68 to 92 percent, respectively.
The rates of unresectable disease among all patients with a CA 19-9 level
≥130 units/mL versus <130 units/mL were 26 and 11 percent, respectively.
Among patients with tumors in the body/tail of the pancreas, more than
one-third of those who had a CA 19-9 level ≥130 units/mL had
unresectable disease.

26. Elevated CA 19-9
Cancer
- Pancreas
- Biliary Cancer (gallbladder, cholangiocarcinoma,
ampullary)
- Hepatocellular
- Gastric, ovarian, colorectal (less often)
- Lung, breast, uterus (rare)
Benign
- Acute cholangitis
- Cirrhosis and other cholestatic diseases (gall stones)

27. Ultrasound
study of 900 patients who underwent
ultrasound to work up painless jaundice,
anorexia, or unexplained weight loss
The sensitivity for detection of all tumors in the
pancreas was 89 percent Among the
779 patients who were followed over time and
established not to have developed a pancreatic
tumor, nine had false-positive US findings
(specificity 99 percent).

28. Ultrasound
Mass in the pancreatic head and dilated common bile duct and
pancreatic duct

29. CT
Sensitivity of CT for pancreatic cancer depends
on technique and is highest (89 to 97 percent)
with triple-phase, helical multidetector row CT
As expected, sensitivity is higher for larger
tumors; in one study, the sensitivity was 100
percent for tumors >2 cm, but only 77 percent for
tumors ≤2 cm in size

30. Endoscopy or ERCP or EUS

31. ERCP or Endoscopic retrograde
cholangiopancreatography
Scope
Duodenum

32. ERCP
Try to
get into
the duct
system

33. ERCP
Inject dye into
the duct system
and look for
compression

34. ERCP
Sensitivity of 92 percent and Specificity of 96 percent for
diagnosing cancer of the pancreas by ERCP
ERCP provides an opportunity to collect tissue samples
(forceps biopsy, brush cytology) for histologic diagnosis.
However, the sensitivity for detection of malignancy
(approximately 50 to 60 percent) is lower than that of
endoscopic ultrasound (EUS)-guided FNA (sensitivity 92
percent)

35. endoscope
EUS
(Endoscopic
Ultrasound
Ultrasound
Tip
Detailed
image of
this area

36. EUS or Endoscopic
Ultrasound
A: met to the
pancreas head
B: lymphoma in
tail
C: endocrine
tumor in isthmus
D: insulinoma in
body
From
Endoscopic
Ultrasound
2014:3

37. EUS used for pain relief with
celiac plexus neurolysis

38. Endoscopic Placement of a
Stent
cancer
stent
duct
pancreas
stent
scope

39. CT Scan – Pancreas Cancer

40. CT Scans

41. CT or PET Scan

43. PET Scans

44. TNM Stage: how far has the
cancer spread, T (tumor) N
(nodes) M (mets) combine all 3
to get Stage

45. Stage IA (T1aN0M0)

46. Stage IB (T2N0M0)
over 2cm, limited to pancreas

47. Stage IIA (T3N0) beyond the
pancreas

48. Stage IIB (T1-3N1M0)

49. Stage III (T4) Unresectable
Cancer has spread to the major blood
vessels near the pancreas. These include
the superior mesenteric artery, celiac axis,
common hepatic artery, and portal vein.

51. Stage IV -
Metastasis
Lung
Liver
Peritoneal
Cavity
Cancer in
Pancreas

52. NCDB Statistics
Stage Incidence Survival/5y
I 8.5% 20%
II 23% 10%
III 14% 2.5%
IV 54% 1.6%

53. 1.2
1
0.8
0.6
0.4
0.2
0
Survival by Stage
0 year 1 year 2 year 3 year 4 year 5 year
Stage I Stage II Stage III Stage IV

54. Survival
Surgery offers the only cure but only 10-20% are
candidates for resection and even in this group
the 5 year survival is only 20% and the median
13 to 20 months
Locally advanced the survival is 8 to 14 months
Up to 60% already have metastases and a
median survival of only 4 to 6 months

56. nccn.org

57. nccn.org/patients

58. Summary of Treatment
1.Resection is the only chance for a cure, and
resectable patients show undergo surgery
without delay followed by adjuvant therapy
2.Borderline resectable patients may benefit
from neoadjuvant therapy and then surgery
3.Unresectable patients may benefit from
chemotherapy or chemoradiation
4.Metastatic disease may benefit from
chemotherapy or other palliative treatments

59. Allen Oldfather Whipple (1881-
1963)
Surgery professor at Columbia
where he developed the resection
for pancreas cancer in 1935 now
called the Whipple Procedure

60. Summary of Treatment
1.Resection is the only chance for a cure, and
resectable patients show undergo surgery
without delay followed by adjuvant therapy
2.Borderline resectable patients may benefit
from neoadjuvant therapy and then surgery
3.Unresectable patients may benefit from
chemotherapy or chemoradiation
4.Metastatic disease may benefit from
chemotherapy or other palliative
treatments

61. Chemotherapy

62. Chemotherapy for Metastatic
Pancreas Cancer
• FOLFIRINOX (oxaliplatin (Eloxatin),
irinotecan (Camptosar) , leucovorin,
fluorouracil)
• Gemzar (gemcitabine) + Abraxane
(albumin bound paclitaxel)
• Gemzar + erlotanib (Tarceva, EGFR
drug)

63. Chemotherapy
Survival Comparisons in Months
5-FU 4.4 Gemzar 5.6
Gemzar 6.8 FOLFIRINOX 11.1
Gemzar 6.7 Gem + Abraxane 8.7

64. Survival with Metastatic
Pancreas Cancer
FOLFIRINOX
Months
Gemzar
NEJM 2011:364:1817

65. Survival with Metastatic
Pancreas Cancer
Gemzar + Abraxane
Months
Gemzar
NEJM 2013;369:1691

66. Pancreas Cancer
www.aboutcancer.com