Gastroenterology and Hepatology

1. PANCREATIC
CANCER

2. INTRODUCTION
• Pancreatic cancer arises when cells in the pancreas, a glandular organ
behind the stomach, begin to multiply out of control and form
a mass.
• A healthy pancreas has 2 types of glands
exocrine gland
endocrine gland
• Over 95 percent of pancreatic
tumors develop in the
pancreas exocrine tissues.

3. EPIDEMIOLOGY
• Age of onset: 60–80 years
• Incidence
- ∼ 3% of all new cancers in the US
-In 2020, 57,600 individuals in the US will be diagnosed with pancreatic
cancer.
• Mortality : accounts for ∼8% of all cancer deaths in the US
• High-risk groups
-African Americans
- Individuals of Jewish ancestry

4. ETIOLOGY
EXOGENOUS RISK FACTORS
• Smoking
• Chronic pancreatitis (especially
when present for more than 20
years)
• High alcohol consumption
• Type 2 diabetes mellitus
• Obesity
• Occupational exposure to chemicals
used in the dry cleaning and
metalworking industries
• Possibly infections with:
• H. pylori (and excess stomach acid)
• Hepatitis B
ENDOGENOUS RISK
FACTORS
• Age > 50 years
• Inherited genetic syndromes (10%
of pancreatic cancers)
• Familial atypical multiple mole melanoma
• (FAMMM) syndrome
• Hereditary breast and ovarian cancer
• syndrome (BRCA1 and BRCA2
• Von-Hippel-Lindau syndrome
• Neurofibromatosis type 1
• Multiple endocrine neoplasia type 1
• Familial pancreatic carcinoma
• Hereditary pancreatitis
• Peutz-Jeghers syndrome

5. CLINICAL FEATURES
In most cases, there are no early
symptoms suggestive
of pancreatic cancer.
Constitutional symptoms
• Poor appetite
• Weight loss
• Weakness
Gastrointestinal symptoms
• Belt-shaped epigastric pain which may
radiate to the back
• Nausea
• Malabsorption, diarrhea (possibly
steatorrhea secondary to exocrine
pancreatic insufficiency)
• Jaundice caused by obstruction of
extrahepatic bile ducts (especially in
tumors of the pancreatic head)
o Courvoisier sign: enlarged, nontender
gallbladder and painless jaundice
o Pale stools, dark urine, and pruritus
• Impaired glucose tolerance (rarely)

6. Hypercoagulability
• Trousseau syndrome: superficial thrombophlebitis (in 10% of cases)
oRecurring thrombophlebitis in changing locations (migratory)
oRed, tender extremities
oClassically associated with pancreatic cancer
• Thrombosis (e.g., phlebothrombosis, splenic vein thrombosis)

7. DIAGNOSIS
• BLOOD
No screening tests available
Tumor markers: used to monitor the progression of cancer and treatment
efficacy
• CA 19-9
• CEA (less specific)
Possibly ↑ lipase
Patients that present with jaundice as the initial
symptom usually undergo an ultrasound examination.
If abdominal pain and weight loss are the initial
presenting symptoms, a CT scan is preferred.

8. ABDOMINAL
ULTRASOUND
• First test
• If ultrasound reveals a pancreatic mass, a contrast-
enhanced CT is performed.
• Poorly defined, hypodense/hypoechoic and
hypovascular mass
• Double-duct sign: With increasing size, tumors of the
pancreatic head may block bile drainage in both the
common bile duct and the pancreatic duct, leading to
dilatation of both structures.

9. Double duct sign in pancreatic head
carcinoma
ERCP: dilated pancreatic duct (PD) and
bile duct (BD, common bile duct), known
as the double duct sign. The vertebral
body (VB) in the image can be used as an
anatomical guide.

10. Endoscopic/magnetic resonance cholangiopancreatography (ERCP/MRCP)
To rule out choledocholithiasis
To assess if biliary decompression is indicated (e.g., in palliative treatment to alleviate
symptoms)
Endoscopic ultrasound (EUS)
Used when other diagnostic tests are inconclusive or to perform fine needle aspiration
Findings similar to transcutaneous ultrasound
Fine needle aspiration: can be done via EUS (preferred) or percutaneously (US or CT-
guided)
Performed in case of unresectable disease to obtain a tissue sample for cytological
evaluation
Can help to differentiate pancreatic cancer from pancreatitis (e.g., chronic or
autoimmune)

11. STAGING OF TUMOR
•Stage 0: Refers to cancer in situ, in which the cancer
has not yet grown outside the duct in which it started
(Tis, N0, M0)

12. Stage IA: The tumor is 2 cm or smaller in the pancreas. It has not spread to
lymph nodes or other parts of the body (T1, N0, M0).
Stage IB: A tumor larger than 2 cm is in the pancreas. It has not spread to
lymph nodes or other parts of the body (T2, N0, M0).

13. Stage IIA: The tumor is larger than 4 cm and extends beyond the pancreas. It has not spread to
nearby arteries, veins, lymph nodes, or other parts of the body (T3, N0, M0).
Stage IIB: A tumor of any size has not spread to nearby arteries or veins. It has spread to 1 to 3
regional lymph nodes but not to other parts of the body (T1, T2, or T3; N1; M0).

14. Stage III: Either of these conditions:
A tumor of any size that has spread to 4 or more regional lymph
nodes but not to nearby arteries, veins, or other parts of the body
(T1, T2, or T3, N2, M0).
A tumor that has spread to nearby arteries and veins and may have
spread to regional lymph nodes. It has not spread to other parts of
the body (T4, any N, M0)

15. Stage IV: Any tumor
that has spread to other
parts of the body

16. TREATMENT

17. SURGICAL
MANAGEMENT
Pylorus-preserving pancreatoduodenectomy (PPPD)
- This involves removal of the duodenum and the pancreatic head,
including the distal part of the bile duct.
Classical Whipple procedure
-This involves removal of the gastric antrum, the duodenum and the
pancreatic head, including the distal part of the bile duct.
Total pancreatectomy - multifocal tumour
For tumours of the body and tail, distal pancreatectomy with
splenectomy is the standard

18. NEOADJUVANT
OR ADJUVANT CHEMORADIOTHERAPY
• To reduce tumor size, improve symptoms, and prolong life
• Chemotherapy or radiation therapy without surgery cannot cure the
patient

20. PAIN MANAGEMENT
• Pharmacotherapy: analgesia according to the WHO step-by-step plan
• Radiotherapy : used in patients with symptomatic metastasis, especially
to the brain and bones (rare)
• Celiac ganglion block (celiac plexus block): when pain management
according to the WHO step-by-step plan fails
CT-guided radiological or endosonographic transgastric puncture of the
celiac ganglion
Installation of test dose local anesthetic
Followed by installation of 95% ethanol to destroy the nerve tissue

21. COMPLICATIONS
• Lymphogenic and hematogenous metastases: often already present at time of diagnosis
Early stage
Nearby lymph nodes
Liver
Advanced stage
Surrounding visceral organs (duodenum, stomach, colon)
Lungs
• Stenosis
Gastric outlet stenosis
Stenosis of the common bile duct
• Other complications
Secondary diabetes mellitus
Disseminated intravascular coagulation (DIC)
Necrolytic migratory erythema

22. PROGNOSIS
• Very aggressive course
• Overall 5-year survival rate: 10%
• 5-year survival rate of metastatic
• pancreatic
• cancer: ∼ 3%
• Median survival for patients who undergo successful resection: ∼ 18
months (5-year survival rate: ∼ 20%)

23. Thank You!