Pancreatic carcinoma is the most dreaded cancer with very dismal prognosis. It is characterized by obstructive jaundice, high colored urine and clay colored stool.

1. PANCREATIC CCAARRCCIINNOOMMAA
““AANN OOVVEERRVVIIEEWW””

5. Introduction
• 3rd most common GIT cancer.
• 4th most common cause of cancer
death
• Death to incidence ratio is one.
( lowest among all types of cancer).
why???
• Male:Female ratio 2:1
• Peak age 65 to 75 yrs
• Common in black americans

6. Risk factors
1- Cigarette smoking.
2- Increased age.
3- Chronic pancreatitis.
4- Increased saturated fat intake.
5- Exposure to nonchlorinated solvents

7. Molecular genetics
• Chronic familial relapsing pancreatitis.
• Familial breast cancer ( BRCA2).
• Peutz –Jeghers syndrome.
• HNPCC (Hereditary non polyposis
colorectal cancer)
• Gardener syndrome.
• Familial atypical mole and melanoma
syndrome.

8. Genetic progression due
to PanIN dysplasia

9. Pathology
• Site:55% head of pancreas;25% body
15% tail; 5% periampulary
• Macroscopic: growth is
hard&infiltrating
• Histology:90% ductal adeno ca;
9% cystic neoplasms
1% endocrine neoplasms
• Spread:Lymphatics to peritoneum &
regional nodes
Blood to liver & lung

10. Presenting symptoms
• Head&Periampulary: Painless progressive
jaundice with palpable GB- “Courvoisier’s Law”;
Vomiting due to duodenal block;
Pruritus,dark urine & clay color stool
• Body: back pain,anorexia,weight loss &
steatorrhea
• Tail: often presents with metastases,malignant
ascites or unexplained anemia

12. Pancreatic Carcinoma
Investigations
• Lab: Elevated total & direct bilirubin
High Alk Phosphatase& GGT
Tumor marker CA19-9 >200U/ml
• USG abd: can detect huge tumors
can’t pickup small mass
• MDCT: with arterial & portal venous
phase is sensitive to pickup
even small hypodense lesions

13. Pancreatic Carcinoma
Investigations
• ERCP & MRCP: “Dual duct sign”
Therapeutic ERCP for palliative stent in
CBD & Duodenum
• Endoscopic Ultrasound:(EUS)
Excellent for staging the tumor
EUS guided pancreatic biopsy

14. Pancreatic Carcinoma
CT Abdomen

15. Pancreatic Carcinoma
ERCP “Dual Duct Sign”

16. Pancreatic Carcinoma
Periampulary Mass&EUS

17. Staging
Stage1:Tumor is limited to pancreas with no
nodes or metastases
Stage2:Tumor extends into bile duct,
peripancreatic tissues or duodenum No nodes
or metastases
Stage3:as stage 2 + positive nodes or celiac or
SMA involvement

18. Staging
Stage4a: Tumor extends to
stomach,colon,spleen or major vessels
with any nodal status and no distant
metastases
Stage4b: Distant metastases with any
nodal status or tumor size

19. Pancreatic Carcinoma
Management
• Rescectable tumors
• Borderline resectability
• Unresectable tumors

20. Resectable tumors
• Normal fat planes between tumor and
SMA, SMV
• Absence of extrapancreatic disease
• Patent SMPV confluence
• No direct extension to celiac axis or
SMA

21. Borderline tumors
• Short segment occlusion of SMPV
confluence with an adequate vessele for
grafting
• Short segment (< 1 cm ) abutment of the
common or proper hepatic artery or
SMA on high quality CT

22. Absolute Contraindications
• Extrapancreatic disease- distant
metastases
• Encasement of coelic axis or SMA
( anything more than short
abutment)

23. Pancreatic Carcinoma
Management

24. Whipple’s Operation
Pancreatoduodenectomy

25. Complictions
• Delayed gastric emptying
• Pancreatic fistula
• Intra-abdominal abscess
• Operative site hge
• GI hge

26. Palliation of unresectable
Pancreatic adenocarcinoma
• Biliary obstruction:
Biliary enteric bypass
Endoscopic biliary stent
placement
Radiographic transhepatic
stent placement

27. Palliation of unresectable
Pancreatic adenocarcinoma
• Gastric outlet obstruction:
Gastroenteric bypass
Endoscopically placed
duodenal stent

28. Palliative Bypass

29. Adjuvant therapy
• 85% local recurrence . RT
• 70% liver metastasis.CT
• 5 FU is the only active agent.
• Gemcitabine.
• 5 FU + Gemcitabine

30. Take home message
• Surgical resection offers the only chance
of long-term survival for patients with
pancreatic cancer
• Patients who undergo surgical resection
for localized, non-metastatic
adenocarcinoma of the pancreas have a 5-
year survival rate of approximately 25%

31. Take home message
• All patients with a suspected pancreatic
neoplasm should be presented and
discussed in a multidisciplinary tumor
board
• Detection and the appropriate
management of premalignant lesions is
mandatory for decreasing mortality.