basic information on introduction, diagnosis and management of ca pancreas

1. Carcinoma Pancreas
Dr. Vigneshwaran
Assistant Professor, General Surgery
SVMCH

2. At the end of this class,
• Burden Of Ca Pancreas
• Risk factors
• Clinical Symptoms
• Investigations
• Management

3. Epidemiology
1. Ca pancreas most commonly occurs between age group of ??
a. 10-20 yrs
b. 30-50 yrs
c. 60- 80 yrs

4. Ca pancreas- epidemiology
• 12TH most common cancer in the US, 9TH MC in world
• Incidence – 44,000 new cases every year
• No of deaths- 38,000 deaths
• Median age of onset- 71 years( elderly group)

5. Ca Pancreas- epidemiology (contd)
• Male sex (1.3:1) and African americans are commonly affected
• 5yr survival after curative resection is only 15-20%
PANCREATIC CANCER – DEADLY DISEASE

6. Epidemiology
1. Ca pancreas most commonly occurs between age group of ??
a. 10-20 yrs
b. 30-50 yrs
c. 60- 80 yrs
Median age of diagnosis is 71 yrs

7. RISK FACTORS

8. Risk factors
2. Risk factors for Ca pancreas include all the following except?(MH06)
a. Obesity
b. Alcohol abuse
c. Peutz jegher syndrome
d. History of partial gastrectomy

9. 3. Hereditary pancreatic carcinoma is associated with all except?(AIIMS 09)
a. Ataxia telangiectasia
b. Peutz jegher syndrome
c. Hereditary pancreatitis
d. FAP

10. Risk factors - Genetics
• Greatest risk factor- strong family history
• 10% all pancreatic cancers- familial
• Lifetime risk if one FDR- 6%
two FDR- 10%
Three FDR- 40%

11. Familial syndromes with Ca pancreas risk (h3-
afp)
• Hereditary pancreatitis
• Hereditary breast and ovarian cancer(BRCA)
• HNPCC
• Ataxia telengectasia
• FAMMM
• Peutz jegher syndrome

12. Risk factors- environmental
• Tobacco – smokers 1 - 3 fold increased risk
• Alcohol
• Occupational exposures- chlorinated hydrocarbons , PAH

13. Risk factors- Medical
• Diabetes mellitus type 2 – cause effect relationship ??
• Diabetes- 2 fold increased risk of PC
• Obesity
• Chronic pancreatitis

14. Risk factors
2. Risk factors for Ca pancreas include all the following except?(MH06)
a. Obesity
b. Alcohol abuse
c. Peutz jegher syndrome
d. History of partial gastrectomy – risk factor for carcinoma stomach

15. 3. Hereditary pancreatic carcinoma is associated with all except?(AIIMS 09)
a. Ataxia telangiectasia
b. Peutz jegher syndrome
c. Hereditary pancreatitis
d. FAP

16. CLINICAL FEATURES

17. 4. MC symptom seen with ca pancreas?
a. Jaundice
b. Weight loss
c. Abdominal pain
d. vomiting

18. Clinical features
• Earliest and MC symptom- obstructive jaundice due to CBD
compression ( hint- mc location )
• pain- typically arises in epigastrium and radiates to the back
• Tumors of body and tail of pancreas- weight loss and pain (MC)

19. 4. MC symptom seen with ca pancreas? (AIIMS 11)
a. Jaundice
b. Weight loss
c. Abdominal pain
d. vomiting

20. Clinical features (contd)- Signs
• Icteric , malnourished
• Palpable gall bladder – COURVOISIER ‘S LAW
• Palpable Left supraclavicular node – VIRCHOW ‘S NODE
• Periumbilical nodule- SISTER MARY JOSEPH NODULE
• Perirectal tumor dissemination – BLUMER’S SHELF

21. COURVOISIER ‘S LAW??
“A Palpable gall bladder in the presence of
jaundice implies that the jaundice is unlikely
to be caused by a stone”

23. Investigations

24. Investigations
5. Investigation of choice for ca pancreas?(PGI88)
a. ERCP
b. MDCT
c. MRI
d. USG

25. Investigations
USG abdomen
• 1ST investigation in obs jaundice ( site of obstruction )
• Non invasive, easily available and cost effective
• Operator dependent
• Poor for visualising gas filled structures

26. Investigations
CECT abdomen
• IOC for ca pancreas
• Visualises the extent of primary lesion – resectability
• Information about distant metastasis
• Radiation exposure
• Contrast allergy, renal impairment – contrast contraindicated

27. CECT ABDOMEN

28. Investigations
MRI abdomen
• Accurately delineates soft tissue masses
• Duct involvement , vascular involvement- best investigation
• No radiation exposure
• Costly, time consuming, not cost effective
• Only for primary lesion

29. Investigations
• ERCP- endoscopic retrograde cholangiopancreatography
• Best investigation for duct visualization – pancreatic, CBD
• Diagnostic and therapeutic procedure
• Invasive procedure
• Requires specialized endoscopists

30. Investigations
5. Investigation of choice for ca pancreas?(PGI88)
a. ERCP
b. MDCT
c. MRI
d. USG

31. MANAGEMENT

32. 6. Whipple s surgery is done for the treatment of?(MH06)
a. Hepatocellular carcinoma
b. Carcinoma of pancreas
c. Small intestinal tumors
d. Acute pancreatitis

33. 7. Components of whipple operation include all the following
except?(MH09)
a. Gastrojejunostomy
b. Duodenojejunostomy
c. Choledochojejunostomy
d. Pancreaticojejunostomy

34. STAGING
• I and II- early cancer
• III- locally advanced
• IV- metastatic

35. Early cancer – Surgical management
• Depends upon location of the tumor
• Head of pancreas – Whipple s procedure
• Body and tail – distal pancreatectomy and enbloc splenectomy

36. Whipple s procedure

37. 7. Components of whipple operation include all the following
except?(MH09)
a. Gastrojejunostomy
b. Duodenojejunostomy
c. Choledochojejunostomy
d. Pancreaticojejunostomy

38. At the end of this class,
• Burden Of Ca Pancreas
• Risk factors
• Clinical Symptoms
• Investigations
• Management

39. Q & A session

40. All of the following signs are seen in
carcinoma pancreas except?
a. Blumers shelf
b. Cullen sign
c. Ascites
d. Virchows node

41. Most common site of metastasis in ca
pancreas??
• Lungs
• Bones
• Liver
• brain

42. Most common complication after whipple
s??(UPSC 08)
• Biliary leak
• Pancreatic leak
• Gastric bleeding
• Wound infection

43. Any Questions???

44. THANK YOU