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Pancreatic Cancer


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Presentation by Dr. Aziz Ahmad, Surgical Oncology, Mills-Peninsula Medical Center, April 23, 2011.

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Pancreatic Cancer

  1. 1. Pancreatic Cancer <br />Aziz Ahmad, MD<br />Surgical Oncology<br />Mills-Peninsula Hospital<br />April 23, 2011<br />
  2. 2. Statistics<br />10th most common cancer <br />4th leading cause of cancer death<br />
  3. 3. Statistics<br />80% of cases are adenocarcinomas from exocrine pancreas<br />Less common exocrine tumors include: <br />IPMN<br />Mucinouscystadenocarcimomas<br />Islet cell tumors<br />Insulin, glucagon, VIP, sandostatin, gastrin, nonsecreting<br />Most common in black males<br />Median age of diagnosis is 70<br />
  4. 4. Statistics<br />Risk Factors:<br />Smoking<br />Low Vegtables & Fruits<br />High red meat<br />High sugar sweetened drinks<br />Chronic pancreatitis (especially hereditary)<br />Diabetes<br />Obesity<br />Genetic (5-10%)<br />Family history, Puetz-Jerghers, HNPCC, FAP, Ataxia-Telangiectasia, Hereditary Pancreatitis, FAMMM-PC <br />
  5. 5. Presentation<br />Nonspecific symptoms<br />Tumors of body and tail (25%)<br />Pain and weight loss<br />Tumors of the Head (75%)<br />Jaundice, steatohrrea, weight loss, Couvoirsier’s sign, pain<br />Labs<br />Increased LFTs, elevated CA19-9<br />
  6. 6. Imaging<br />Ultrasound<br />Bile duct distension<br />Mass <br />CT scan with IV contrast<br />Quality of imaging continues to improve<br />Triple phase CT (pancreas protocol) 90% accurate at finding lesions<br />Endoscopic ultrasound<br />Help find lesions not seen on CT<br />Help determine resectability<br />Excellent way to get biopsy <br />ERCP<br />Therapeutic as well as diagnostic<br />
  7. 7. Treatment<br />Needs to be multimodal<br />Primary care, radiology, gastroenterology, surgery, & oncology<br />Surgery is the only cure<br />Cure only in those with complete resections<br />Otherwise outcome is poor with surgery<br />
  8. 8. Treatment<br />Finding lesions early (hardest job)<br />High index of suspicion by primary care<br />Modern CT technology <br />Gastroenterologist with specialized skill in ERCP and EUS<br />Surgeons with experience in pancreatic surgery<br />Radiation/medical oncology up to date with standard of care and knowledge of any promising clinical trials<br />
  9. 9. What is resectable?<br />Tumors localized to pancreas <br />15-20% of patients<br />Locally advanced disease in patients with vascular involvement of less than 50% of portal vein <br />Or lymph node spread that is limited <br />10-15%<br />Resection contraindicated in patients:<br />>50% involvement of portal vein<br />Invasion or encasement of SMA (or hepatic artery)<br />
  10. 10. Non Surgical Candidates<br />Palliative chemoradiation<br />Clinical trials<br />Median survival is about 8 months<br />Palliative endoscopic or surgical procedures<br />5-10% locally advanced patients not initially surgical candidates can be downstaged<br />
  11. 11. General Survival Data<br />Overall prognosis seems dismal<br />70-80% of patients present as inoperable due to metastatic disease or locally advanced disease<br />Median survival only 4-6 months<br />20-30% are operable with localized or resectable locally advanced disease<br />Successful operation can give five year survivals from 20-30%<br />
  12. 12. Surgical Procedures<br />Tumors of the Body and Tail<br />Laparoscopic distal pancreatectomy<br />Removal of body & tail of pancreas<br />spleen<br />
  13. 13. Surgical Procedures<br />Head of the pancreas: Whipple Procedure<br />Removal of:<br />Distal stomach<br />Duodenum and proximal jejunem<br />Head of pancreas<br />Gallbladder and common bile duct<br />
  14. 14. Complications<br />Whipple Procedure<br />bleeding<br />Gastroparesis<br />Pancreatic duct leak<br />Bile duct leak<br />Diabetes<br />malabsorption<br />Distal pancreatectomy<br />Bleeding<br />Pancreatic duct leak<br />Malabsorption<br />diabetes<br />
  15. 15. Complications<br />Particularly Whipple procedure thought to have poor surgical outcomes<br />Mills-Peninsula experience in the last 40 Whipples: <br />5% 60 day mortality<br />Even in patients that recur after 2-3 years, quality of life is excellent before symptoms of disease return<br />
  16. 16. Adjuvant Treatment<br />Most patients go on to get adjuvant treatment<br />Gemcitibine based chemotherapy<br />Radiation to the surgical bed<br />Even with this 70-80% of patients recur<br />
  17. 17. Why Does it Recur?<br />Pancreas with rich vascular and lymphatic supply<br />Early lymph node spread<br />Microscopic at the time of surgery<br />Currently best chemo with only 25-30% response rate<br />
  18. 18. Conclusion<br />So at this time the best answer is to catch the disease early<br />In those that you can detect disease early, all hope is not lost<br />With an operation, you not only give a chance for cure, but you give hope<br />