This Presentation focuses on different aspects of pancreatic carcinoma

1. Pancreatic Carcinoma
Jibran Mohsin
Resident, Surgical Unit I
SIMS/Services Hospital Lahore

2. Outline
• Introduction
• Pathophysiology
• Etiology
• Epidemiology
• Clinical Presentation
• Workup
• Staging
• Treatment
• Prognosis

3. Introduction
• Worldwide, ranks 13th in incidence
• BUT 8th as a cause of cancer death
• Worst prognosis of all malignancies
DISTRIBUTION
• Head(Periampullary) or Neck  66-75 %
• Body  15-20%
• Tail  5-10 %

4. Introduction
Classification of Pancreatic Tumors
Parenchymal
Exocrine
tumors
Endocrine
tumors
Stromal

5. Introduction
Classification of Pancreatic Tumors
• Exocrine (95%)Tumors-WHO classification
– Benign
• Serous cystadenoma
• Mucinous cystadenoma
• Intraductal papillary-mucinous adenoma
• Mature cystic teratoma
– Borderline
• Mucinous cystic tumor with moderate dysplasia
• Intraductal papillary mucinous tumor with moderate dysplasia
• Solid pseudopapillary tumor
– Malignant
• Ductal Adenicarcinoma (75-80% of all exocrine tumor)
• Serous/mucinous cystadenoma
• Intraductal mucinous papillary tumor

6. Introduction
Classification of Pancreatic Tumors
• Endocrine Tumors
• Primary Connective tissue cancers
– Lymphomas
Endocrine Tumor Source Clinical Presentation
Insulinoma Beta cells Whipple’s triad
Gastrinoma G cells Peptic ulcer
Glucagonoma Alpha cells Diabetes,
Necrolytic Migratory erythema
Vipoma-Pancreatic Cholera
(Verner Morrison Syndrome)
Watery Diarrhea
Hypokalemia
Achlorhydria ( WDHA syndrome)
Somatostatinoma Delta/S cells Diabetes, Steatorrhea, Gallstones

7. Introduction
Periampullary Carcinoma
Type of Carcinoma Frequency
Adenocarcinoma of head of pancreas 50 %
Tumor from ampulla of vater 30%
Distal bile duct carcinoma 10%
Duodenal carcinoma adjacent to ampulla 10%

8. Pathophysiology

9. Pathophysiology
SPREAD
• Typically, metastasizes to regional lymph nodes, then to liver and
less commonly to lungs
• Also directly invade surrounding viscera
– Duodenum, stomach, and colon
• Metastasize to any surface in abdominal cavity via peritoneal
spread ( ascites- ominous prognosis)
• Spread to skin as painful nodules
• Metastasis to bone is uncommon
• Rare spread to brain but can produce meningeal carcinomatosis

10. Etiology
Frequency Etiology
40 % Sporadic
30% Smoking
(most common environmental risk factor)
40 pack-year 5 time high risk
20% Dietary factors
(BMI > 25 in early adulthood)
(High energy diet rich in fat, low fibre)
Fresh fruits and vegetables low risk
Processed red meat high risk
Alcohol per se/Poultry/dairy/coffee No risk
5-10 % Hereditary
(2-3 x risk if parent or sibling has cancer)
80-95% K-ras2
85-98%CDKN2
50% p53
55% Smad4(DPC4)
BRCA-2, HER-2/neu, p16

11. Etiology
• Diabetes
– DM of 5 year duration  2 fold high risk
• Chronic Pancreatitis
– 26 fold high risk
– Of 20 year duration  4 % cases develop Pancreatic CA
• Hereditary Pancreatitis
– Mutation in PRSS1 gene
– 50 fold high risk
– 40 % develop CA by age of 70

12. Etiology
ASSOCIATIONS
• Peutz Jegher syndrome
• Multiple endocrine neoplasia(MEN I)
• Hereditary Nonpolyposis Colonic Cancer(HNPCC)-controversial-MSH2/MLH1 gene
• Familial Adenomatous Polyposis(FAP)- APC gene
• Gardner Syndrome
• Familial atypical multiple mole melanoma syndrome (FAMMM)-CDKN2A gene
• Von Hippel-Lindau (VHL) syndrome-VHL tumor suppressor gene
• Ataxia telangiectasia
• Hereditary breast(BRCA 2> BRCA 1) and ovarian cancers

13. Epidemiology
INCIDENCE
• Worldwide8-12 cases per 100, 000 persons
per year

14. Epidemiology
RACE
• Highest incidence  African American males
GEOGRAPHICAL
• High in Native Hawaiian males, men of korean,
Czech, Latvian and New zealand Maori
ancestry

15. Epidemiology
GENDER
Male > Female
AGE
Median age at diagnosis in whites 69 years
Median age at diagnosis in blacks 65 years
Mean 60-65 years

16. Clinical Presentation
• Early clinical diagnosis difficult due to
nonspecific symptoms and subtle in onset
• Typically present as gradual onset of
nonspecific symptoms such as anorexia,
malaise, nausea, fatigue, and midepigastric or
back pain
• Significant weight loss characteristic feature
LOCATION CLINICAL PRESENTATION
HEAD(peri ampullary) and NECK Weight loss and Painless Obstructive jaundice
BODY and TAIL Weight loss, PAIN and Mass

17. Clinical Presentation
MIDEPIGASTRIC PAIN
– can be in RHC/LHC depending on location of tumor
– Most common presenting symptom
– Mild-moderate(1/3rd cases) –severe(1/3rd cases)
– Unrelenting in nature
– More at night
– Increased by food intake and lying flat
– Often but always radiating to midback or lower-back
• Indicates invasion of retroperitoneal splanchnic nerve plexus
OR
• Pancreatic duct obstruction/stasis OR
• Disruption of nerve sheath

18. Clinical Presentation
WEIGHT LOSS
• Cancer-associated anorexia
• Subclinical malabsorption from pancreatic
exocrine insufficiency caused by pancreatic duct
obstruction
– Diarrhea, Steatorrhoea
• Nausea and early satiety from GOO and delayed
gastric emptying

19. Clinical Presentation
(PAINLESS*) OBSTRUCTIVE JAUNDICE
• Most characteristic sign of CA head of pancreas
• Get medical attention before tumor size enlarges to cause pain
• Short duration, severe, progressive
• Intermittent if necrosis of tumor occurs
• preceded by pruritis-skin bile salt deposition
– Scratch marks
• Acholic/clay colored stools
• Tea colored/Darkening of urine
_______________________________________________________________
*To distinguish it from choledcholithiasis BUT this aphorism is not accurate

20. Clinical Presentation
OTHERS
• Depression
– More common in pancreatic cancer than other abdominal
tumors
– 11 times increase risk of suicide especially early postoperative
period
• Migratory thrombophlebitis
– Trousseau sign of malignancy OR
– Trousseau syndrome
– Seen in 10 % cases
– Due to release of PAF(Platelet aggregating
factors) from tumor or its necrotic material
Trousseau himself died of CA pancreas who had migratory
thrombophlebitis

21. Trousseau syndrome
(Migratory thrombophlebitis)

22. Clinical Presentation
OTHERS
• Venous thrombosis
• Marantic endocarditis
• New onset of diabetes within 1 year in old age
• 1st episode of acute pancreatitis in old age

23. ……………………..
Rule out Pancreatic Cancer in patient older than 60 years
with NEW diagnosis of DM or increase in insulin reqirement in
pre existind diabetes and without any other diabetic risk
factors

24. ……………………………………
Rule out pancreatic cancer in an elderly patient presenting for
1st time with acute pancreatitis without any known
precipitating factors

25. Clinical Presentation-Examination
• Epigastric Mass
– Non mobile, smooth, soft/hard, (non)tender, not moving
with respiration
• Palpable gallbladder(+clinical jaundice)
– i.e. Courvoisier sign
– Nontender, soft globular, smooth, moving with respiration,
mobile horizontally, dull on percussion
– 25-30 % cases of CA head of pancreas
– 50 % cases of periampullary CA
• Ascites
– Shifting dullness and fluid thrill

26. Clinical Presentation
• Hepatomegaly
– Enlarged+ smooth, firm and nontender
Hydrohepatosis
• Dilated bilairy channels
– Multiple hard nodules Mets
• Splenomegaly
– due to portal/splenic vein thrombosis
– Seen in 10 % cases

27. Clinical Presentation
• Sister Mary Joseph nodule(s)/node/sign
– Subcutaneous metastases
– Paraumbilical region
– Signifies advanced disease
– spread of cancer cells to the umbilicus include
• direct transperitoneal spread,
• via the lymphatics which run alongside the obliterated umbilical vein
• hematogenous spread, or
• via remnant structures such as the faclciform ligament, median umbilical ligament, or a
remnant of the vitelline duct.
• Mass in rectovesical pouch(Blumer’s Shelf)
– Metastatic mass, palpable on DRE
*Sister Mary Joseph Dempsey was the surgical assistant of William J. Mayo at St.
Mary’s Hospital n Rochester, Minnesota from 1890 to 1915. She drew Mayo's
attention to the phenomenon, and he published an article about it in 1928. The
eponymous term Sister Mary Joseph nodule was coined in 1949 by Hamilton
Bailey.

28. Clinical Presentation
• Virchow’s node*(or Signal node)
– Called Troisier’s sign**
– Left supraclavicular palpable lymph node
– Behind the medial end of left clavicle
Right: Charles Émile Troisier
Left:Rudolf Carl Virchow
* Rudolf Virchow(1821–1902), the German pathologist who
first described the gland and its association with gastric
cancer in 1848.
**TheFrench pathologist Charles Emile Troisier noted in 1889
that other abdominal cancers, too, could spread to the node.

29. Clinical Presentation
Sister Mary Joseph nodule Virchow/signal node

30. Differential diagnosis
• Retroperitoneal masss/tumor/LN
• Advanced adherent CA stomach
• Advanced CA transverse colon
• CBD stone
• Bile duct stricture
• LN compressing CBD
• Cholangiocarcinoma of CBD
• Chronic pancreatitis

31. Workup
• Hematological Investigations
• Serological Investigations
• Radiological Investigations
• Histopathological investigation

32. Hematological Investigations
• CBC
– Anemia of chronic disease
– Thrombocytosis
• Liver Function Test
– Raised total/conjugated (van den Bergh’s test)bilirubin
– Raised ALP/GGTP
– Low albumin and altered PT/INR
• Serum amylase/lipase*
– Raised in < 50 % cases of resectable tumor v/s
– 25 % cases of irresectable tumor
*5% cases present initially with acute pancreatitis

33. Serological Investigations
• Carbohydrate Antigen(CA) 19-9 (<33-37 U/mL)
– Sialylated oligosaccharide most commonly found on circulating
mucins in cancer patients
– Also normally produced within cells of biliary tract
• Can be elevated in 10% cases of benign diseases of pancreas, liver and
bile ducts
– Elevated in 75-85 % cases of pancreatic CA
• 5-10 % patients lack CA 19-9 producing enzyme
– In absence of biliary obstruction, intrinsic liver disease, or
benign pancreatic disease, value> 100 U/mL  highly specific
for malignancy especially pancreatic

34. Serological Investigations
• Carbohydrate Antigen(CA) 19-9
– Used along with imaging studies to determine
resectability potential
• <4% cases with CA 19-9 > 300 U/mL have resectable
tumors
– Demerit:
• Least sensitive for small, early stage pancreatic
carcinomas i.e. not effective as screening tool or early
detection
– 0.2 % positive results in asymptomatic cases
– 4.3 % positive in early symptomatic cases

35. Serological Investigations
• Carbohydrate Antigen(CA) 19-9
– Used in staging and follow up
• Case with <100 U/mL unlikely to have occult
metastatic disease and may not need staging
lapsroscopy prior to resection
• Surrogate marker for clinical response to therapy
• Preoperative >50 U/mL  associated with higher
chances of recurrence

36. Serological Investigations
• Carcinoembryonic antigen(CEA)
– High molecular weight glycoprotein found
normally in fetal tissues
– Elevated in only 40-45 % of cases of pancreatic CA
– NOT sensitive or specific for pancreatic CA
• As it is also elevated in others benign and malignant
conditions
Sensitivity Specificity
CA 19-9 NO YES
CEA NO NO

37. Radiological Investigations
Computed Tomography Scan
• Mainstay of initial diagnostic modalities used for assessing patients
suspected to have pancreatic carcinoma
• Triple-phase spiral/3D CT scan 90 % accurate in determining
resectability potential (as accurate as EUS)
• To detect size, extent, nodal status , portal vein involvement
• More accurate than EUS in predicting involvement of SMA
• Malignant tumors appear as lower density lesions
• CT guided FNA can also be done
• Demerit:
– Small tumors still be missed even with most advanced CT scanning

38. CT scan findings suggestive of unresecatable disease
• Invasion of hepatic artery or SMA
• Enlarged LN outside boundaries of resection
• Ascites
• Distant metastases

39. CT scan showing a pancreatic adenocarcinoma
• Gallbladder (gb) is distended
because of biliary obstruction. The
superior mesenteric artery (sma) is
surrounded by tumor, making this
an unresectable T4 lesion.
• 2-cm pancreatic adenocarcinoma
(mass) causing obstruction of
both the common bile duct (cbd)
and pancreatic duct (pd).

40. Radiological Investigations
Transcutaneous Ultrasonography
• Less useful than CT because
– pancreas is often obscured by overlying gas from stomach,
duodenum and colon.
– Depth of pancreas from anterior abdominal wall limits imaging
to lower(2-5 MHz) frequency, hence lower resolution
– Detect only 60-70 % of pancreatic CA
– >40% lesions <3 cm missed(similar to CT)
• Only useful as an initial screening test in evaluating patients
who present with possible obstructive jaundice
– However, other studies should then be performed to definitively
diagnose the source of biliary obstruction.
– Use to visualize gall bladder, liver , CBD size, LN, portal vein,
ascites

41. Radiological Investigations
Endoscopic Ultrasonography
• Obviates the physical limitations of TUS
– High frequency USG(7.5-12 MHz) with very high resolution (subcentimeter)
images
• INDICATED if high suspicion of pancreatic CA and CT is normal
• MOST SENSITIVE and SPECIFIC diagnostic test for pancreatic cancer
– Negative EUS is nearly 100 % specific at ruling out presence of a pancreatic
neoplasm
– Detection rates of 99-100 % for all pancreatic carcinomas including <3 cm
– As accurate as ERCP or MRCP for assessing etiology of obstructive jaundice
– Equivalent to dual-phase spiral CT for assessing tumor resectability potential
– Superior to CT as mean of assessing T stage of tumor e.g. portal vein/ SMV
involvement
• EUS-guided FNA can also be done at time of EUS diagnosis
• Demerit:
– Inferior to CT in assessing arterial involvement and distant metastases
– Poor at detecting occult nodal involvement(same as CT)

42. Endoscopic ultrasound of a 2.2-cm pancreatic adenocarcinoma
of the head of the pancreas obstructing the common bile duct
(CBD) but not invading the portal vein (PV) or superior
mesenteric vein (SMV).

43. Radiological Investigations
Endoscopic Retrograde Cholangiopancreatography
• Highly sensitive means of detecting pancreatic +/- biliary
ductal abnormalities in pancreatic cancer
– 90-95 % cases have ERCP findings
– Brush cytology and forceps biopsy can be taken(< 50 % yield)
• Demerits:
– Findings not always highly specific for pancreatic cancer
– Difficult to differ from changes of chronic pancreatitis
– More invasive and carries 5-10 % risk of significant
complications
• Reserved as therapeutic procedure for biliary obstruction OR for
diagnosis of unusual neoplasm such as intraductal pancreatic
mucinous neoplasms(IPMN)
– Limited staging information

44. Radiological Investigations
Magnetic Resonant Imaging
• NOT superior to spiral CT scanning in
diagnosing and staging pancreatic cancer
Magnetic Resonant Cholangiopancreatography
• Noninvasive method for imaging the biliary
tree and pancreatic duct

45. Radiological Investigations
Positron Emission Tomography
• Uses 18F-fluorodeoxyglucose(FDG) to image primary tumor
and metastatic disease
• Useful in detecting occult metastatic disease
• Alone offer no additional benefits over high-quality CT
• PET-CT more sensitive than conventional imaging for
detection of pancreatic cancer

46. Needle Aspiration
IN FAVOUR
• Provide proof of pathology
pre operatively
• Exclude unusual pathology
• Evidence of disease before
initiation of
multidisciplinary treatment
e.g. neoadjuvant
chemotherapy
AGAINST
• Biopsy will not alter therapy
• May result in seeding*,
infection, bleeding, fistula
and leak
• Interfere with definitive
surgery
• Increases the cost of care
*Risk of peritoneal contamination with CT guided biospy(50-85 % yeild) is uncommon
*EUS guided aspiration done through tissue that would ultimately included in operative field
and resected. Thus, it is MOST EFFECTIVE(85-95 % accurate) means for getting biopsy
_____________________________________________________________________________

47. Needle Aspiration
• Tissue diagnosis before performing
pancreatoduodenectomy is not essential
– Negative biopsy doesn't rule out malignancy in face of
clinical and radiological clues
• Tissue diagnosis mandatory if
– Neoadjuvant/adjuvant chemotherapy to be given
– Clinical presentation more suggestive of alternative
diagnosis such as lymphoma or pancreatic islet cell
tumors

48. Staging
• Once probable diagnosis has been established, next issue is
whether lesion is amenable to surgical resection
• Pancreatic masses characterized as
– Resectable( only 20 % of all cases)
– Borderline resectable (based on experience/skill of surgeon and
overall health of patient)
– Irresectable
• Noncurative resections for pancreatic cancer provide no
survival benefits
• Hence, WHEN NOT TO OPERATE decision requires accurate
preoperative staging

49. American Joint Committee on Cancer (AJCC)- 2002
Tumor (T)
• TX - Primary tumor cannot be assessed
• T0 - No evidence of primary tumor
• Tis - Carcinoma in situ
• T1 - Tumor limited to the pancreas, 2 cm or smaller in greatest dimension
• T2 - Tumor limited to the pancreas, larger than 2 cm in greatest dimension
• T3 - Tumor extension beyond the pancreas (eg, duodenum, bile duct, portal or
superior mesenteric vein) but not involving the celiac axis or superior mesenteric
artery
• T4 - Tumor involves the celiac axis or superior mesenteric arteries
Regional lymph nodes (N)
• NX - Regional lymph nodes cannot be assessed
• N0 - No regional lymph node metastasis
• N1 - Regional lymph node metastasis
Distant metastasis (M)
• MX - Distant metastasis cannot be assessed
• M0 - No distant metastasis
• M1 - Distant metastasis

50. T staging for pancreatic carcinoma

51. American Joint Committee on Cancer (AJCC)- 2002
Stage T N M Description
0 Tis N0 M0
IA T1 N0 M0 Limited to pancreas≤ 2 cm
IB T2 N0 M0 Limited to pancreas > 2 cm
IIA T3 N0 M0 Extends beyond pancreas but doesn't involve arteries
IIB T1-3 N1 M0 Any tumor without artery involvement with LN +
III T4 Any N M0 Tumor involves arteries (unresectable)
IV Any T Any N M1 Any tumor with distant metastases
• Stage grouping for pancreatic cancer is as follows:

52. Staging
Stage at time of presentation Frequency of cases
Stage I disease-confined to primary site 7 %
Locally advanced disease 26%
Metastatic to distant nodes/sites 52%
Unknown 15%

53. Staging
MODALITIES
• According to 2011 NCCN guideline, CT scan primary mean for staging
– Triphasic multidetector spiral(helical) dynamic contast-enhanced CT with
thin-slice, cross sectional imaging is recommended i.e. pancreas protocol CT
scanning
• EUS 70-80 % accurate for correct staging/predicting resecatbility
• Staging Laparoscopy (with US 98 % accurate)
– Some use it routinely in all patients with pancreatic caner
– Others, including NCCN 2011 guidelines, advise selective approach with any of
following criteria:
• CA 19-9 > 1000 U/mL or marked wt loss
• Low volume ascites
• Body/tail of pancreas tumor
• Borderline resectable tumors/equivocal findings of metastsis
• Size> 4 cm
• CBD lymphadenopathy
– Doesnot show vascular invasion or retroperitoneal invasion which makes
apparently resectable tumor irresectable one

54. Evaluation Algorithm

55. Treatment
• Surgery
– primary mode of treatment
• Chemoradiation
– Adjuvant or neoadjuvant therapy
– Irresectable disease
• Palliative therapy

56. Treatment
SURGERY
• Typically, extrapancreatic disease precludes curative
resection and surgical treatment may be palliative at best
• Invasion of SMV/portal vein NOT absolute contraindication
– Can be resected partially with as much as 50 % narrowing of
lumen
– Complete reconstruction is possible e.g. using native veins as
replacement( internal jugular, greater saphenous or splenic)
• Invasion of SMA/celiac/hepatic arteries still barrier to
resection

57. Treatment
SURGERY
• In operable cases
– Whipple Procedure
– Traverso-Longmire pylorus preserving
pancreaticoduodenectomy(PPPD)
– Fortner’s regional pancreatectomy (extended
whipple’s)
– Total pancreatectomy
– Distal pancreatectomy
• In inoperable cases
– Roux en Y choledochojejunostmoy

58. Whipple Procedure
• Indicated for periampullary tumors
• Involves removal of
– Pancreatic head and neck
– 40 % distal stomach + C loop of duodenum + 10 cm proximal jejunum
– Lower end of CBD with gall bladder
– Peripancreatic + pericholedochal + paraduodenal + perihepatic nodes
• Contiuity maintained by
– Choledochojejunostomy
– Pancreaticojejunostomy ( or pancreatogastrostomy)
– Gastrojejunostomy

59. Whipple Procedure

60. Whipple Procedure
• Mortality 2-8 %
• Complications
– Delayed gastric emptying-25 %
• Require NG decompression
– Pancreatic fistula -14 %
– Infection- intraabdominal abscess, wound infection,
cholangitis, pancreatitis, pneumonia
– Bile/pancreatic anastomotic leak
• Preoperative biliary drainage (ERCP) increases the rate
of complications

61. Surgery
Traverso-Longmire pylorus preserving pancreaticoduodenectomy(PPPD)
• Duodenum is cut 2 cm distal to pylorus
• Continuity maintained by anastomosing with
jejunum
Fortner’s regional pancreatectomy(extended Whipple’s)
• Resection like whipple’s along with removal of segment of
SMV and clearance of all regional nodes
• Portal vein continuity maintained by synthetic vascular graft

62. Surgery
Total Pancreatectomy
• Least commonly performed procedure
• Morbidity comparable to that of whipple procedure
• Highest mortality rate i.e. 8.3 %
• Indicated in pancreatic neck tumor
• Merits:
– Possibility of multicentric disease
– Recurrence after whipple procedure
– No morbidity due to pancreatic fistula or pancreatitis
– Malignant cell may present in pancreatic duct
• Complication
– Severe resistant brittle diabetes mellitus

63. Surgery
Distal Pancreatectomy
• Lower mortality(3.5 %) than standard whipple
• Indicated for tumor located in body and tail of pancreas
• Limited curative resection as these tumor present later with higher
unresectability rate
• Involves isolation of distal portion of pancreas containing tumor
followed by resection of that segment, with over sewing of distal
pancreatic duct
• Complications: Pancreatic stump leak, hemorrhage, endocrine
insufficiency

64. Surgery
Roux en Y choledochojejunostomy
• Palliative procedure done along with
gastrojejunostomy after doing cholecystectomy
• Better than cholecystojejunostomy as it may
get blocked either by tumor infiltration or by
bile sludge or inflammation

65. Chemoradiotherapy-Palliative
• Indicated in advanced irresectable/metastatic
pancreatic cancer
– Gemcitabine(1000 mg/m2 over 1 hour IV) montherapy
• 1st line therapy (NCCN 2011 guidelines) in poor performance status
– FOLFIRINOX ( LV5-FU + oxaliplatin +irinotecan)
• 1st line therapy (NCCN 2011 guidelines) in good performanc status
– Gamcitabine + nab(nanoparticle ablumin bound)-paclitaxel
• Indicated if FOLFIRINOX contraindicated
– Capecitabine +/- erlotinib
• Second line therapy if refactory to gemcitabine
– OTHERS
• Gamcitabine + docetaxel + capecitabine (GTX regimen)
• Gemcitabine +/- erlotinib-FDA approved
/capecitabine(controversial)

66. Chemoradiotherapy-Palliative
• Daily use aspirin over a period of 5 years
reduces death caused by several cancers
including pancreatic cancer

67. Chemoradiotherapy- Adjuvant
• Gemcitabine
• S-1(Taiho Pharmaceutical, Japan)
Chemoradiation-Neoadjuvant
No form of neoadjuvant therapy is regarded as
standard form of therapy( NCCN 2011)

68. Palliative Therapy
PAIN
• Nacrotic analgesics used early and in adequate dosages
– Combining with TCAs or antiemetics potentiate their analgesic effect
– Sustainted release Morphine sulfate
• Neurolysis of celiac ganglion if refactory pain
– Performed transthoracically or transabdominally by invasive radiology
or anesthesiology, transgastrically using EUS-guided Fine needle
injection or intra operatively
• Radiation therapy(4000 cGy units) can palliate pain but does not
affect patients survival
• ERCP- stent if pain due to obstruction of pancreatic/bilairy tract

69. Palliative Therapy
JAUNDICE
• Warrants palliation if patient has pruritus or RHC
pain or developed cholangitis
• Endoscopic placement of plastic(replace every 3
months) or metal (5 months) stents
• Surgical biliary decompression/bypass
DUODENAL OBSTRUCTION-20%
• Endoscopic stenting(poor operative candidates)
• Gastrojejunostomy

70. PROGNOSIS…….fatal disease
5 year survival after successful surgery  NOT guarantee of CURE
Without Surgery Successful curative resection
(about 20 % patients)
Median survival rate 4-6 months 12-19 months
1 year survival rate 24 %
Overall 5 year survival rate 5 % 15-20 %
Location Time of presentation Prognosis
HEAD and NECK Early presentation-obstructive
jaundice
Better prognosis
Body and Tail Late presentation(Mass) Worse prognosis

71. PROGNOSIS…….fatal disease
Stage 5 year survival rate
Localized stage 20.3 %
Regional stage 8.0 %
Distant stage 1.7%
Unknown stage 4.1%

72. PROGNOSIS…….fatal disease
POOR PROGNOSTIC FACTORS
• Growth > 3 cm*
• Nodal involvement*
– Ratio of positive nodes to total nodes removed more important
than margin positivity
• Portal vein infiltration
• Liver /Lung mets*
• Ascites*/Trousseau’s sign/Left supraclavicular LN spread
• White bile on table
• Associated problems like pancreatitis, DM
• Liver dysfunction*
*Present in patient mentioned in case summary

73. Future Therapy
• Immunotherapeutic gene therapy
– To assist immune system in recognizing cancer cells
• Replacement of tumor suppressor gene function
• Inactivation of oncogenes
• Suicide gene therapy
– Transgene introduced that converts an inactive notoxic drug
into active cytotoxic agent
– E.g. Herpes simplex virus-thymidine kinase system

74. Case Summary
• 60 year old male, resident of Nankana Sahib presented with pain in
epigastrium for last 1 year,
– chronic in onset, progressive, boring in nature, radiating directly to back,
aggravated with food intake, relieved temporarily with medication, mild
initially then moderate in intensity,
– associated weight loss, anorexia, yellowish discoloration of sclera, dark color
urine, abdominal distension
• Past medical history shows HCV + with chronic liver disease
• Examination revealed elderly male of lean physique with abdominal
distension, vitally stable, with Jaundice +, BUT no pallor/bruises/palpable
lymphadenopathy
• Abdominal Examination revealed it to be distended, tensed, tender(upper
portion) with horizontally compressed umbilicus, splenomegaly, fluid thrill
+, NO paraumblical nodule

75. Case Summary
• Hematological investigations showed
Parameter Value
Hemoglobin 13.5
Total leucocyte Count 6.2
Platelet count 172
Sodium/potassium 137/3.8
Urea/creatinine 70/0.9
Prothromin time 14/13 (INR 1.1)
Total bilirubin 14.2
Conjugated bilirubin 11.0
Alkaline phosphatase 340
Gamma GT 202
Total protein/Albumin 5.6/2.0
ALT/AST 46/41

76. Case Summary
• Transcutaneous Ultrasound showed
– Liver normal in size and echotexture.No focal lesion
seen
– Biliary channels/CBD/portal vein normal
– Gall Bladder distended full of thick sludge and
debrinous
– Pancreas showed 46x24x57 mm heterogenous area
into body and tail
– Spleen measures 14.5 cm and mildly enlarged
– Minimal abdominopelvic ascites

77. Case Summary
• Pancreas protocol CT scan showed
– Infiltrative primary pancreatic mass involving its body and tail which
would be most concerning for a primary pancreatic cancer.
– Associated upper abdominal lymphadenopathy
– Significant intra and extra hepatic biliary dilation probably secondary
to upper abdominal lymphadenopathy
– Gall Bladder distended with no primary GB mass
– Obvious slightly irregular focal low density in segment 4 of liver, most
consistent with liver metastases
– Significant abdominopelvic ascites
– Nodularity/thickening along peritoneal reflection and omental
infiltration
– Multiple basal pulmonary nodules regarded as metastasis
– Sclerotic focus in right ischial bone, may represent bone mets
___________________________________________________________
IMPRESSION: Metastatic primary T4 pancreatic cancer (Stage 4)

78. Case Summary
• Currently, patient is on following treatment
Rationale Medication
Partial Parenteral Nutrition
Inf 10 % D/W 1000 ml IV OD
Inf Aminovil 500 mg IV BD
Pain Inj Toradol IV TDS
Inj N/M diluted in 10 ml N/S, give 3 ml IV TDS
Vomiting Inj gravinate IV TDS
Inj Onset IV TDS
Stress ulcers Inj Novoteph 40 mg IV BD
Antibiotic Inj oxidil 1g IV BD
Ascites Inj Lasix 20 mg IV OD
Tab aldactone 100 mg PO OD
Tab Inderal 10 mg PO TDS
Inj Albumin 100 ml IV OD for 3 days
Malabsorption of vit K(fat soluble) Inj Vit K IM OD for 3 days

79. Case Summary
• As a palliative measure for biliary
decompression, ERCP planned on 24th March
2014

80. THANK YOU…………………..

81. Surgical Triad
Measure Thrice
Think twice
Cut once