Pancreatic carcinoma

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Pancreatic carcinoma

  1. 1. Pancreatic Carcinoma By- Piyush Giri Intern
  2. 2. Anatomy • Pancreas is derived from Greek ‘pan’ meaning all and ‘kreas’ flesh. • 12-15–cm long J-shaped soft, lobulated, retroperitoneal organ. It lies transversely, although a bit obliquely, on the posterior abdominal wall behind the stomach, across the lumbar (L1- 2) spine divided into Head, Neck and Tail. • Weighs approximately 80 grams, Head occupies 30% by weigh and body and tail together constitutes 70%
  3. 3. Head of Pancreas • The head of the pancreas lies in the duodenal C loop in front of the inferior vena cava (IVC) and the left renal vein. • The uncinate process is an extension of the lower (inferior) half of the head toward the left; it is of varying size and is wedged between the superior mesenteric vessels (vein on right, and artery on left) in front and the aorta behind it.
  4. 4. • The lower (terminal) part of the CBD runs behind (or sometimes through) the upper half of the head of pancreas before it joins the main pancreatic duct (MPD) to form a common channel (ampulla of vater).
  5. 5. Body and tail • The body and tail of the pancreas run obliquely upward to the left in front of the aorta and left kidney. The pancreatic neck is the arbitrary junction between the head and body of the pancreas. Portal vein lies behind the neck of the pancreas. The narrow tip of the tail of the pancreas reaches the splenic hilum in the splenorenal (lienorenal) ligament.
  6. 6. Ducts of Pancreas 1. Duct of Wirsung begins in the tail of pancreas and runs on posterior surface of body and head and receives tributaries at right angle along its length, joins bile duct in wall of duodenum to form hepato pancreatic ampulla ( ampulla of vater) opening on major duodenal papilla. 2. Accessory pancreatic duct which begins at lower part of head and opens into minor duodenal papilla.
  7. 7. Histology • Composed of exocrine acinar tissue and cluster of endocrine cells known as islets of Langerhans.
  8. 8. Blood supply 1. Pancreatic branches of splenic artery branch of Celiac artery 2. Superior pancreaticoduodenal artery branch of Gastroduodenal artery 3. Inferior pancreaticoduodenal artery branch of Superior Mesenteric artery • Capillaries draining the islet cells drain into portal vein forming pancreatic portal system.
  9. 9. Nerve supply • Parasympathetic supply is from Vagus nerve • Sympathetic innervation is from splanchnic nerves.
  10. 10. Physiology of Pancreas • Can be divided into Endocrinal and Exocrinal functions. • Exocrinal function includes; Pancreatic digestive enzymes being released in response to secretin and Cholecystokinin secreted from duodenal mucosa. • Pancreatic juice constitutes: • 98% water and 2% solid • Solid contents includes: • Organic (0.8%) and Inorganic (1.2%) • Pancreatic juice helps in digestion of proteins, carbohydrate and fats.
  11. 11. Contents of Pancreatic juice Organic Components (0.8%) Pancreatic enzymes: 1 Pancreatic amylase 2 Pancreatic lipase and colipase 3 Phospholipases 4 Trypsinogen 5 Chymotrypsinogen 6 Procarboxypeptidases 7 Proelastase 8 Procollagenase and nuclease • Inorganic components (1.2%) Cations Sodium Potassium Calcium Magnesium Zinc Anions bicarbonate Chloride Sulphate
  12. 12. Endocrinal function • Endocrinal part of pancreas formed by Islets of Langerhans secretes Insulin ( B cells), Glucagon ( A cells), Somatostatin ( D cells) and Pancreatic polypeptide ( F cells) • Endocrinal part helps in -Carbohydrate metabolism -Lipid metabolism -Protein metabolism -Ion transport: specially increasing potassium transport into the cell -Growth and development.
  13. 13. Pancreatic Carcinoma
  14. 14. Introduction • Epidemiology • Pancreatic cancer is sixth leading cause of cancer deaths in the UK and fourth highest cause of death in USA • Incidence is 10 cases per 100000 population per year • Incidence has declined slightly over last 25 years. • World wide it constitutes 2-3% of all cancers
  15. 15. Classification • A. Exocrine tumours. • B. Endocrine tumours. • C. Lymphomas.
  16. 16. Exocrine Tumours • Benign : 1. Benign cystadenoma (rare) • Malignant 1. Adenocarcinoma 2. Squamous cell carcinoma 3. Combination of adenocarcinoma and squamous cell carcinoma 4. Cystadenoma: occurs commonly in body and tail of the pancreas and attains a large size.
  17. 17. Endocrine Tumours • 1. Insulinoma (B cells) • 2. Gastrinoma ( G cells) • 3. Glucagonoma ( A cells) • 4. Vipoma – Pancreatic cholera ( Verner- Morrison syndrome) • 5. Somatostatinoma (D cells)
  18. 18. Risk Factors Demographic factors 1. Age (peak incidence 65-75 years) 2. Male gender 3. Black ethnicity Environment/Life style 1. Cigarette smoking
  19. 19. Risk factors Genetic factors and medical conditions 1. Family history: Two first degree relatives with pancreas cancer relative increases 18 to 57 fold and Germline BRCA2 mutation (rare). 2. Hereditary pancreatitis (50 to 70 fold increased risk). 3. Chronic pancreatitis ( 5 to 15 fold increased risk) 4. Hereditary non polyposis colorectal cancer. 5. Ataxia telangiectasia. 6. Peutz-jeghers syndrome.
  20. 20. continued. 7. Familial breast - ovarian cancer syndrome. 8. Familial atypical multiple mole melanoma. 9. Familial adenomatous polyposis – risk of ampullary/ duodenal carcinoma. 10. Diabetes Mellitus.
  21. 21. Clinical features • History: • Age: peak in 65 – 75 years • Sex: Mostly male • Ethnicity: more commonly in Black community • Carcinoma of the head of the pancreas: • Most common presenting symptom being Jaundice : Very common, is painless, progressively deepening, can be on and off (intermittent) and associated with nausea and epigastric discomfort and majority of cases it precedes pain • Pain in abdomen can be first symptom, though it is usually a painless condition and present at advanced stage. • Occasionally symptoms are similar to those of acute pancreatitis
  22. 22. Presentation of Ca. of head of Pancreas Contd. • Bowel habit: Diarrhoea; foul smelling, pale stool which is quite common and steatorrhoea • Anorexia and loss of weight are very common • Other non-specific symptom can be: vague discomfort • Upper abdominal symptoms in recently diagnosed diabetic especially in one above 50 years with no family history or obesity should raise suspicion
  23. 23. • Carcinoma of body and tail • Pain in epigastric region is the cardinal symptom, radiating through the back aggravating on lying down and decreasing when sitting up so that the patient spends the night sitting up with arms folded across the chest. • Thrombophelbitis migrans; Trousseau’s sign.
  24. 24. • On Examination: • Jaundice • Left supraclavicular palpable lymph node • Scratch marks • Weight loss • Palpable liver • Palpable spleen (rare) • Palpable Gallbladder (Courvoisier's law) • Tumour is seldom palpable • Ascites may be present only in late cases.
  25. 25. Investigation 1. Complete blood count: Raised bilirubin; raised direct bilirubin, Serum albumin decreased, PT prolonged and serum alkaline phosphatase is increased 2. Ultrasound: if bile duct is dilated in jaundiced patient; tumour in head of pancreas can be suspected. 3. Contrast-enhanced CT scan: preferred test • Tumour resectable? • Hepatic or peritoneal or lymphatic metastasis? • Encasement of Superior mesenteric, hepatic or coeliac artery? • Local spread?
  26. 26. 4. MRI and MRI angiography: information comparable to CT scan 5. ERCP: if diagnostic doubt (small tumours not detected on CT) and biliary stent can also be done to relieve jaundice, obtain brush cytology and biopsy to confirm diagnosis. 6. EUS: useful if CT fails to demonstrate tumour • Tissue diagnosis • Vascular invasion? • Distinguishing cystic tumours from pseudocysts • Transduodenal or transgastic FNA or Trucut biopsy to be done, it avoids spillage of tumour cells into the peritoneal cavity
  27. 27. 7. Diagnostic laparoscopy • Identify small peritoneal and liver metastases. • Can also be combined with laparoscopic ultrasonography 8. Tumour marker CA 19-9 • Not highly specific or sensitive, useful to identify recurrence. 9. Barium meal: Reverse 3 sign in periampullary carcinoma 10. Urine for bile salts ( Hay’s test), bile pigments (Fouchet’s test)
  28. 28. Treatment • Needs to be multimodal: Primary care, radiology, gastroenterology, surgery, & oncology • Surgery is the only cure Cure only in those with complete resections • Only 10-15% are operable • 40-50% are locally advanced • 40-50% have distant spread to liver or lungs
  29. 29. Treatment • Surgical management • Palliation
  30. 30. Surgical management • Pylorus preserving pancreatoduodenectomy • Whipple’s procedure • Distal pancreatectomy • Total pancreatectomy
  31. 31. Pylorus preserving pancreatoduodenectomy • Standard for tumour of pancreatic head • It involves removal of duodenum, pancreatic head, distal part of bile duct and local lymphandectomy • It preserves antrum and pylorus • Yields more physiological outcome with no difference in survival or recurrence rate
  32. 32. Pancreatoduodenectomy • Indication • in conditions where entire duodenum has to be removed eg. FAP • In cases tumour is encroaching first part of duodenum or distal stomach • PPPD does not achieve clear resection margin
  33. 33. Procedure of Pancreatoduodenectomy • Three phages 1. Exploration and assesment 2. Resection 3. Reconstruction Procedure: • Cholecystectomy done • Bile duct and hepatic artery exposed with removal of local lymphatic tissue • Division of gastroduodenal artery and portal vein is visualized • Distal part of gastric antrum , duodenum and right colon is mobilized • Superior mesenteric vein is exposed • Dissection into the plane between vein and the pancreatic substance • Fourth part is dissected and freed from ligamentum treitz • Decide to continue to resection?
  34. 34. Procedure contd. • If yes • Jejunum is divided 20-30 cm downstream from duodenal jejunal flexure and mesentery of proximal jejunum detached. • First part of duodenum is divided • Uncinate process is separated from superior mesenteric artery and vein, working upwards to upper bile duct which is divided and release of specimen achieved • Retro peritoneal lymph node within the operative field is removed
  35. 35. Procedure contd. • Reconstruction • Pancreatic stump, divided bile duct, duodenal stump and stomach are anastomosed on to jejunum in that order • Pancreas can also be anastomosed to posterior wall of stomach • Or can separate Roux loop of jejunum created and anastomsed to that.
  36. 36. Distal Pancreatectomy • In tumours affecting body and tail • Distal pancreatectomy with splenectomy is standard • In benign condition though spleen may be preserved • Antibiotic prophylaxis and immunization prior to splenectomy against pneumococci, meningococci and Haemophilus influenza required.
  37. 37. Total Pancreatectomy • In multifocal tumour (eg. Multifocal tumour,) • If body and tail of pancreas is too inflamed or too friable to achieve safe anastomosis. • If tumour is adherent to portal or superior mesenteric vein, short segment can be removed with reconstruction.
  38. 38. Complication • Bleeding • Gastroparesis • Pancreatic duct leak • Bile duct leak • Diabetes • Malabsorption • Infection • Octreotide may be administered in perioperative period to reduce likelihood of leak.
  39. 39. TNM staging • Tis : In situ carcinoma and Pancreatic Intraepithelial Neoplasm (PaIN) • T1 : Growth limited to pancreas T1a <2 cm, T1b > 2 cm • T2 Extension occurs to duodenum, bile duct, peripancreatic tissue • T3 Extension to stomach, spleen, colon and large vessels • N0 No lymph node • N1 +ve lymph node • M0 - No metastases • M1 - +ve metastases
  40. 40. Adjuvant therapy • In a large multicentre European study, adjuvant radiotherapy or chemoradiotherapy showed no advantages • Chemotherapy with 5- fluorouracil provided overall benefit • Combination of gemcitabine and 5 Flurouracil in combination are under trial • Patient with adenocarcinoma are offered adjuvant chemotherapy
  41. 41. Palliation • In unresectable tumours • Locally advanced • Locally advanced disease in patients with vascular involvement of less than 50% of portal vein • Invasion or encasement of SMA (or hepatic artery)
  42. 42. Palliation of pancreatic cancer • Relieve jaundice and treat biliary sepsis 1. Surgical biliary bypass 2. Stent placed at ERCP or percutaneous transhepatic cholangiography • Improving gastric emptying 1. Surgical gastroenterostomy 2. Duodenal stent
  43. 43. Palliation cont. • Pain relief 1. Stepwise escalation of analgesia 2. Coeliac plexus block 3. Transthoracic splanchicectomy • Symptoms relief and quality of life 1. Feeding jejunostomy 2. Enzyme replacement 3. Treatment of diabetes 4. Encourage normal activity
  44. 44. Feeding jejunostomy • Indications • Inability to use the mouth, stomach, or esophagus for feeding due to dysfunction • Loss of brain function secondary to head trauma or cerebrovascular accident. • Two types: 1. Witzel jejunostomy: site of placing is 30cm from duodenojejunostomy 2. Needle jejunostomy: using catheter of small size
  45. 45. Procedure for Feeding jejunostomy (Witzel) • The patient is placed supine on the operating room table • Midline incision is made • Dissection is done through the subcutaneous tissues using cautery • The midline between the layers of the rectus muscle is identified, anterior fascia is incised, the preperitoneal fat is identified and grasped • The peritoneum is identified and incised using thus allowing entry into the abdomen
  46. 46. Procedure contd. • Cautery is used to open the peritoneal cavity cephalad (toward the head) and caudally (toward the feet).An abdominal wall retractor is placed if needed to increase exposure. • The small bowel is traced proximally (toward the head) until the ligament of Treitz marking the juncture between the duodenum and the jejunum is located. • Approximately 30 cm is measured from the ligament of Treitz for optimal placement of the enterostomy • The loop of small bowel where the entry is to be grasped
  47. 47. Procedure contd. • incision on its antimesenteric border through the longitudinal muscle layer for about 8 cm • At the distal end, a hole through into the lumen • Insert a feeding catheter or a long Ryle's tube, through this hole for about 10 cm • Close the gut around it with continuous catgut, as doing the Lembert suture of a bowel closure • Make a second incision in his abdominal wall above where this loop of jejunum will comfortably lie. Draw the end of the tube back through his abdominal wall
  48. 48. Procedure contd. • Draw jejunum and the interior of his abdominal wall together with a purse string suture • Close his abdomen and anchor the tube to abdominal wall with stitch, or with tape • Advantages of Feeding jejunostomy: 1. Comfortable 2. Can be kept for long time 3. Easier to do
  49. 49. Reference • Bailey and love’s Short Practice of Surgery 25th edition • SRB’s manual of surgery 3rd edition • A manual of Clinical Surgery, S.Das 8th edition.
  50. 50. Thank you Have a nice day

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