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1. Pancreatic Ca
Canada Golden Short Notes

2. Risk Factors
 Risk factors for pancreatic cancer? • Elderly • DM o
DM is very common in patients with pancreatic
cancer o Usually diagnosed within preceeding 2 yrs
of cancer dx • Smoking • Diet o High intake of fact
and or meat o Fruits are protective • Chronic
pancreatitis o 2% per decade • Hereditary
pancreatitis (40% risk by age 70) o Beginning
screening at age 35; CT or EUS • Familial pancreatic
cancer o up to 7-8% of patients with pancreatic
cancer have a 1st degree relative with the disease •
Hereditary cancers (HNPCC, BRAC2, Peutz-
Jehgers)

3.  What are 3 important gene mutations in pancreatic
cancer? • p16 – 95% • K-ras – 90% • P53 – 75%

4. Potential candidates for screening for
pancreatic cance
An affected individual with PJS
An affected individual with hereditary pancreatitis
Three or more first-, second-, or third-degree relatives with pancreatic cancer,
with ≥1 pancreatic cancer in a first-degree relative*
A known mutation carrier of
a BRCA1 ,
•
BRCA2 , p16 , MLH1 ,
•
MSH2 ,
•
MSH6 ,
•
or PMS2
•
mutation and
≥1 first- or second- degree relative with pancreatic cancer

5.  The optimal timing and frequency of screening for
pancreatic cancer in individuals at elevated risk is
uncertain. Some expert groups recommend screening for
high-risk individuals who have a 5 or 10-fold or higher
risk of pancreatic cancer ( table 2 ) [ 150,154 ]. The
optimal time to begin screening is unclear, but some
groups recommend beginning at age 40 for those with
hereditary pancreatitis and 10 years before the age at
which pancreatic cancer was first diagnosed in
individuals with an inherited predisposition. In patients
with PJS, screening for pancreatic cancer is
recommended at age 30 years. There is no consensus
on the appropriate interval for screening and also no
consensus as to the optimal screening strategy

6.  What are the different epithelial cell types in the
pancreas? Which does the majority of malignant
neoplasms of the pancreas arise from? • Acinar cells
– 80% of gland • Ductal cells – 10-15% of gland •
Endocrine (islet) cells – 1-2% of gland • > 95% of the
malignant neoplasms of the pancreas arise from the
exocrine elements of the galnd – ductal and acinar
cells o ductal adenocarcinoma accounts for 85-90%
of pancreatic tumors ƒ
60-70% of tumors are in the
head ƒ
5-10% of tumors are in the body ƒ
10-15% are
in the tail What is courvoisier’s sign? • Palpable
nontender gallbladder: ~ 1/3 of patients

7.  What are the criteria for unresectability of pancreatic
cancer? • Presence of disease distant to the
pancreas o liver, peritoneal mets • Contiguous
invasion of adjacent organs such as the stomach or
colon o not including the duodenum • Arterial
encasement (celiac axis or SMA) • Venous occlusion
(PV or SMV)

8.  What is the TNM staging of pancreatic cancer? • Tis
– carcinoma in situ • T1 – tumor limited to the
pancreas 2 cm or less in size • T2 – tumor limited to
the pancrease > 2 cm in size • T3 – tumor extends
directly into any of the following: duodenum, bile
duct, peripancreatic tissues • T4 – tumor extends
directly into any of the following: stomach, spleen,
colon, adjacent large vessels • N0/N1 – no nodes vs
node positive • M0/M1 – no mets vs +ve mets

9.  What % of patients are candidates for potential
curative resection? • ~15% What is the 5-yr survival
of pancreatic cancer in patients undergoing surgery?
• 10-25% What is the mortality and morbidity of a
Whipple’s surgery? • < 3% mortality and 20%
morbidity What chemotherapic agent has been
shown to be useful? • Gemcitabine has been shown
to be most useful • small, but statistically significant
survival advantage over 5-FU o 5.7 vs 4.4 months o
1 year survival 18% vs 2%