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Diagnosis & Staging of Pancreatic Cancer

Presentation by Dr. Vino J. Verghese: "The Diagnosis and Staging of Pancreatic Cancer"

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Diagnosis & Staging of Pancreatic Cancer

  1. 1. The diagnosis and staging of Pancreatic Cancer Vino J. Verghese, M.D Gastroenterology Consultants of the Peninsula
  2. 2. Pancreatic Cancer <ul><li>Fourth leading cause of cancer related death </li></ul><ul><li>Surgery offers the only chance of a cure </li></ul><ul><li>Only 15-20% of patients are candidates for surgery </li></ul><ul><li>5 year survival after a Whipple resection </li></ul><ul><li>30% for node negative disease </li></ul><ul><li>10% for node positive disease </li></ul>
  3. 3. Pancreatic Cancer <ul><li>Recent data suggests that survival may be improving </li></ul><ul><li>One of the strongest predictors for increased survival on recent studies has been the use of adjuvant chemoradiation therapy </li></ul><ul><li>Three year survival was significantly higher among those who received chemoradiation (45% vs. 30%) compared to those who did not </li></ul>
  4. 4. Risk Factors <ul><li>Hereditary (5-10%) </li></ul><ul><li>Smoking </li></ul><ul><li>Diabetes </li></ul><ul><li>Chronic pancreatitis, Hereditary pancreatitis </li></ul><ul><li>?Alcohol ?Coffee </li></ul><ul><li>?Obesity/High fat diet </li></ul><ul><li>-Aspirin </li></ul>
  5. 5. Surveillance for High Risk <ul><li>Not yet proven to improve survival </li></ul><ul><li>Screening begins 10 years before the age at which the diagnosis was made </li></ul><ul><li>AGA recommends CT and EUS </li></ul><ul><li>?CA 19-9 </li></ul><ul><li>?MRI </li></ul><ul><li>?ERCP </li></ul>
  6. 6. Clinical Features <ul><li>Pain </li></ul><ul><li>Jaundice </li></ul><ul><li>Weight loss </li></ul><ul><li>Steatorrhea </li></ul><ul><li>New onset Diabetes </li></ul><ul><li>Acute pancreatitis </li></ul><ul><li>Thrombophlebitis </li></ul>
  7. 7. Physical Findings <ul><li>Abdominal mass </li></ul><ul><li>Enlarged nontender gallbladder </li></ul><ul><li>Virchows node </li></ul><ul><li>Ascites </li></ul><ul><li>Hypercoaguable state </li></ul>
  8. 8. Lab Findings <ul><li>Abnormal LFTs </li></ul><ul><li>Tumor markers (CEA) </li></ul><ul><li>Sensitivity and Specificity of 80% </li></ul><ul><li>Sensitivity is limited in small potentially resectable tumors </li></ul><ul><li>Not recommended for screening </li></ul><ul><li>Values >37U/ml useful for discriminating benign from malignant causes </li></ul>
  9. 9. Lab Findings (CEA) <ul><li>Not recommended as an indicator of Operability </li></ul><ul><li>Serial monitoring at 3 month intervals is recommended in post-op patients and in those with unresectable disease receiving chemo-radiation therapy </li></ul>
  10. 10. Differential Diagnosis <ul><li>Chronic pancreatitis </li></ul><ul><li>Neuro-endocrine tumors </li></ul><ul><li>Auto-immune pancreatitis </li></ul><ul><li>Lymphoma </li></ul>
  11. 11. Diagnosis <ul><li>Transabdominal ultrasound, CT scan, MRI, ERCP and EUS are the modalities most commonly used </li></ul><ul><li>Contrast enhanced helical CT is the preferred method to diagnose and stage Pancreatic Cancer </li></ul><ul><li>CT is useful for detecting metastasis and for determining resectability </li></ul><ul><li>EUS is most useful for T staging as well as for determining vascular involvement </li></ul>
  12. 12. Diagnosis (cont.) <ul><li>PET scanning is useful for detecting occult metastatic disease </li></ul><ul><li>US, ERCP, MRI and MRCP are also useful in the diagnosis </li></ul>
  13. 13. Criteria of Unresectability <ul><li>Distant Metastasis </li></ul><ul><li>Extrapancreatic involvement </li></ul><ul><li>Vascular involvement </li></ul><ul><li>Encasement of SMV </li></ul><ul><li>Involvment of SMA, Aorta, Celiac Axis, Hepatic artery </li></ul><ul><li>Borderline Resectability </li></ul>
  14. 14. Staging of Pancreatic Cancer <ul><li>T1: Tumor limited to pancreas <2cm </li></ul><ul><li>T2: Tumor limited to pancreas >2cm </li></ul><ul><li>T3: Tumor extends beyond pancreas without involvment of CA or SMA </li></ul><ul><li>T4: Tumor involves CA or SMA </li></ul><ul><li>N1: Regional lymph node metastasis </li></ul><ul><li>M1: Distant metastasis </li></ul>
  15. 15. Helical CT for Staging <ul><li>Arterial and Portal venous phase </li></ul><ul><li>Diagnostic test of choice for Pre-operative Staging </li></ul><ul><li>High Predictive value for unresectability (90%) </li></ul><ul><li>65-90% Predictive value for resectability </li></ul>
  16. 16. Endoscopic Ultrasound
  17. 17. Endoscopic Ultrasound
  18. 18. Endoscopic Ultrasound
  19. 19. Endoscopic Ultrasound
  20. 20. Endoscopic Ultrasound
  21. 21. Endoscopic Ultrasound
  22. 22. Endoscopic Ultrasound
  23. 23. Endoscopic Ultrasound
  24. 24. Endoscopic Ultrasound
  25. 25. Pancreatic Cyst
  26. 26. Pancreatic cyst
  27. 27. Pancreatic cyst
  28. 28. EUS for staging <ul><li>T stage accuracy as high as 80-95% </li></ul><ul><li>N stage accuracy as high as 80% </li></ul><ul><li>Diagnostic accuracy of EUS is further enhanced by the ability to perform needle biopsies of pancreatic lesions with a sensitivity >90% </li></ul><ul><li>Accuracy of staging is operator dependent (increases with staging >100 tumors) </li></ul>
  29. 29. Pancreatic Cancer
  30. 30. Pancreatic Cancer
  31. 31. Pancreatic Cancer
  32. 32. Pancreatic Cancer
  33. 33. Pancreatic Cancer
  34. 34. Pancreatic Cancer
  35. 35. Pancreatic Cancer
  36. 36. Pancreatic Cancer
  37. 37. Pancreatic Cancer
  38. 38. Pancreatic Cancer
  39. 39. Staging <ul><li>Dual phase helical CT is routinely performed as the first step </li></ul><ul><li>EUS is most useful in patients with equivocal findings on CT scan and those with potentially resectable disease </li></ul><ul><li>EUS can be used to assess for the presence of metastatic lymph nodes as well as to obtain a tissue diagnosis when needed </li></ul>
  40. 40. EUS Guided Biopsy <ul><li>Fine needle aspiration with a 22 guage needle is most commonly employed </li></ul><ul><li>EUS guided Trucut biopsy is also available </li></ul><ul><li>Biopsy helps to differentiate between adenocarcinomas, lymphomas and neuroendocrine tumors </li></ul><ul><li>Most patients want to know the diagnosis before undergoing surgical resection </li></ul>
  41. 41. Neuroendocrine tumor
  42. 42. Neuroendocrine tumor
  43. 43. Pancreatic Cancer
  44. 44. Pancreatic Cancer
  45. 45. Pancreatic Cancer
  46. 46. Pancreatic Cancer
  47. 47. Pancreatic Cancer- tail
  48. 48. Pancreatic Cancer- tail
  49. 49. Peripancreatic node
  50. 50. Celiac nodes
  51. 51. Celiac nodes
  52. 52. Pancreatic Cancer
  53. 53. Pancreatic Cancer
  54. 54. Pancreatic Cancer
  55. 55. Pancreatic Cancer
  56. 56. Pancreatic Cancer
  57. 57. Celiac Block
  58. 58. Celiac Block
  59. 59. Pancreatic Cancer
  60. 60. Pancreatic Cancer
  61. 61. Pancreatic Cancer
  62. 62. Conclusions <ul><li>Although surgery offers the only chance of a cure in Pancreatic cancer, survival may be improved with use of adjuvant chemoradiation </li></ul><ul><li>CT is useful for detecting metastasis and for determining resectability </li></ul><ul><li>EUS is most useful for T staging as well as for determining vascular involvement </li></ul><ul><li>EUS can be used to assess for the presence of metastatic lymph nodes as well as to obtain a tissue diagnosis when needed </li></ul>