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Pancreas Cancer 
www.aboutcancer.com
Pancreas Cancer 
Incidence (2014 Data) Deaths 
46,420 (2.8%) 39,590 (6.8%) 
The 5 year survival is only 6.7% 
Life time ri...
2014 Statistics 
Male Female 
New Cases 23,530 (2.7%) 22,890 (2.8%) 
Deaths 20,170 (6.5%) 19,420 (7%)
Age and Pancreas Cancer 
Median age is 71
New Cases per 100,000
Trends in Incidence and 
Survival
Stage and Survival - SEER 
Stage Incidence Survival/5y 
Local 9% 25.8% 
Regional 28% 9.9% 
Distant 53% 2.3%
Risk factors for pancreatic 
cancer include the following 
- Smoking 
- Obesity 
- Personal history of diabetes or chronic...
Symptoms 
Most patients present with pain (in the back) 
weight loss or jaundice 
Tumors in the head of the pancreas are m...
Bile: yellowish fluid produced in the liver that aids 
in digestion of fat in the small intestine 
Liver
Bile: passes through the common bile duct through the 
head of the pancreas on it’s way to the duodenum 
Liver 
Hepatic Du...
Bile duct carries the bilirubin through the head of the 
pancreas on it’s way to the duodenum 
Tail of the Pancreas 
Commo...
Tumors in the head of the pancreas are more likely 
to have jaundice 
Tail of the Pancreas 
Common Bile Duct 
Common Bile ...
Tumors in the head of the pancreas are more likely 
to have jaundice 
Tail of the Pancreas 
Common Bile Duct 
Common Bile ...
Head of the Pancreas Tumor 
Blocking the pancreatic duct 
and common bile duct 
Common bile Duct 
Pancreatic 
duct 
Common...
Tail of the Pancreas 
Common Bile Duct 
Common Bile Duct Body of the Pancreas 
Head of the Pancreas 
Tumor 
Tumors in the ...
Symptoms of Pancreas 
Cancer 
• Asthenia (weakness) – 86 percent 
• Weight loss – 85 percent 
• Anorexia (no appetite)– 83...
Signs of Pancreas Cancer 
• Jaundice (yellow) – 55 percent 
• Hepatomegaly (large liver) - 39 percent 
• Right upper quadr...
Pathology 
Ductal adenocarcinoma accounts for about 85% of all 
neoplasms. And more than 95% of all pancreatic 
cancers ar...
Parts of the Pancreas 
Portal Vein 
Aorta 
Superior Mesenteric Vein 
Head Body Tail
Cancer in the Head of the 
Pancreas 
Head 
Tail 
Body
Location of Pancreas Cancer 
• 60 to 70 percent of exocrine pancreatic cancers 
are localized to the head 
• 20 to 25 perc...
Location of Pancreas Cancer 
• 60 to 70 percent of exocrine pancreatic cancers 
are localized to the head 
• 20 to 25 perc...
Tests used to evaluate and stage 
pancreas cancer 
• Routine blood tests e.g. liver products 
like bilirubin 
• Elevated t...
CA 19-9 
The reported sensitivity and specificity rates of CA 19-9 for pancreatic 
cancer range from 70 to 92, and 68 to 9...
Elevated CA 19-9 
Cancer 
- Pancreas 
- Biliary Cancer (gallbladder, cholangiocarcinoma, 
ampullary) 
- Hepatocellular 
- ...
Ultrasound 
study of 900 patients who underwent 
ultrasound to work up painless jaundice, 
anorexia, or unexplained weight...
Ultrasound 
Mass in the pancreatic head and dilated common bile duct and 
pancreatic duct
CT 
Sensitivity of CT for pancreatic cancer depends 
on technique and is highest (89 to 97 percent) 
with triple-phase, he...
Endoscopy or ERCP or EUS
ERCP or Endoscopic retrograde 
cholangiopancreatography 
Scope 
Duodenum
ERCP 
Try to 
get into 
the duct 
system
ERCP 
Inject dye into 
the duct system 
and look for 
compression
ERCP 
Sensitivity of 92 percent and Specificity of 96 percent for 
diagnosing cancer of the pancreas by ERCP 
ERCP provide...
endoscope 
EUS 
(Endoscopic 
Ultrasound 
Ultrasound 
Tip 
Detailed 
image of 
this area
EUS or Endoscopic 
Ultrasound 
A: met to the 
pancreas head 
B: lymphoma in 
tail 
C: endocrine 
tumor in isthmus 
D: insu...
EUS used for pain relief with 
celiac plexus neurolysis
Endoscopic Placement of a 
Stent 
cancer 
stent 
duct 
pancreas 
stent 
scope
CT Scan – Pancreas Cancer
CT Scans
CT or PET Scan
PET Scans
TNM Stage: how far has the 
cancer spread, T (tumor) N 
(nodes) M (mets) combine all 3 
to get Stage
Stage IA (T1aN0M0)
Stage IB (T2N0M0) 
over 2cm, limited to pancreas
Stage IIA (T3N0) beyond the 
pancreas
Stage IIB (T1-3N1M0)
Stage III (T4) Unresectable 
Cancer has spread to the major blood 
vessels near the pancreas. These include 
the superior ...
Stage IV - 
Metastasis 
Lung 
Liver 
Peritoneal 
Cavity 
Cancer in 
Pancreas
NCDB Statistics 
Stage Incidence Survival/5y 
I 8.5% 20% 
II 23% 10% 
III 14% 2.5% 
IV 54% 1.6%
1.2 
1 
0.8 
0.6 
0.4 
0.2 
0 
Survival by Stage 
0 year 1 year 2 year 3 year 4 year 5 year 
Stage I Stage II Stage III St...
Survival 
Surgery offers the only cure but only 10-20% are 
candidates for resection and even in this group 
the 5 year su...
nccn.org
nccn.org/patients
Summary of Treatment 
1.Resection is the only chance for a cure, and 
resectable patients show undergo surgery 
without de...
Allen Oldfather Whipple (1881- 
1963) 
Surgery professor at Columbia 
where he developed the resection 
for pancreas cance...
Summary of Treatment 
1.Resection is the only chance for a cure, and 
resectable patients show undergo surgery 
without de...
Chemotherapy
Chemotherapy for Metastatic 
Pancreas Cancer 
• FOLFIRINOX (oxaliplatin (Eloxatin), 
irinotecan (Camptosar) , leucovorin, ...
Chemotherapy 
Survival Comparisons in Months 
5-FU 4.4 Gemzar 5.6 
Gemzar 6.8 FOLFIRINOX 11.1 
Gemzar 6.7 Gem + Abraxane 8...
Survival with Metastatic 
Pancreas Cancer 
FOLFIRINOX 
Months 
Gemzar 
NEJM 2011:364:1817
Survival with Metastatic 
Pancreas Cancer 
Gemzar + Abraxane 
Months 
Gemzar 
NEJM 2013;369:1691
Pancreas Cancer 
www.aboutcancer.com
Pancreas Cancer
Pancreas Cancer
Pancreas Cancer
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Pancreas Cancer

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Understanding pancreas cancer, including the causes, symptoms, diagnostic tests and the best treatment options for this very serious malignancy

Published in: Health & Medicine

Pancreas Cancer

  1. 1. Pancreas Cancer www.aboutcancer.com
  2. 2. Pancreas Cancer Incidence (2014 Data) Deaths 46,420 (2.8%) 39,590 (6.8%) The 5 year survival is only 6.7% Life time risk of developing this cancer is 1.5%
  3. 3. 2014 Statistics Male Female New Cases 23,530 (2.7%) 22,890 (2.8%) Deaths 20,170 (6.5%) 19,420 (7%)
  4. 4. Age and Pancreas Cancer Median age is 71
  5. 5. New Cases per 100,000
  6. 6. Trends in Incidence and Survival
  7. 7. Stage and Survival - SEER Stage Incidence Survival/5y Local 9% 25.8% Regional 28% 9.9% Distant 53% 2.3%
  8. 8. Risk factors for pancreatic cancer include the following - Smoking - Obesity - Personal history of diabetes or chronic pancreatitis - Family history of pancreatic cancer or pancreatitis - Certain hereditary conditions
  9. 9. Symptoms Most patients present with pain (in the back) weight loss or jaundice Tumors in the head of the pancreas are more likely to have jaundice, Those that arose in the body or tail, more likely pain and weight loss.
  10. 10. Bile: yellowish fluid produced in the liver that aids in digestion of fat in the small intestine Liver
  11. 11. Bile: passes through the common bile duct through the head of the pancreas on it’s way to the duodenum Liver Hepatic Duct Common Bile Duct Duodenum Pancreatic Duct
  12. 12. Bile duct carries the bilirubin through the head of the pancreas on it’s way to the duodenum Tail of the Pancreas Common Bile Duct Common Bile Duct Body of the Pancreas Head of the Pancreas
  13. 13. Tumors in the head of the pancreas are more likely to have jaundice Tail of the Pancreas Common Bile Duct Common Bile Duct Body of the Pancreas Head of the Pancreas Tumor in the Head of the Pancreas Obstruct the Bile Duct
  14. 14. Tumors in the head of the pancreas are more likely to have jaundice Tail of the Pancreas Common Bile Duct Common Bile Duct Body of the Pancreas Head of the Pancreas Pancreatic Duct Tumor in the Head of the Pancreas
  15. 15. Head of the Pancreas Tumor Blocking the pancreatic duct and common bile duct Common bile Duct Pancreatic duct Common bile Duct cancer Duodenum
  16. 16. Tail of the Pancreas Common Bile Duct Common Bile Duct Body of the Pancreas Head of the Pancreas Tumor Tumors in the body or tail are more likely to present with pain or weight loss
  17. 17. Symptoms of Pancreas Cancer • Asthenia (weakness) – 86 percent • Weight loss – 85 percent • Anorexia (no appetite)– 83 percent • Abdominal pain – 79 percent • Epigastric pain (stomach) – 71 percent • Dark urine – 59 percent • Jaundice – 56 percent • Nausea – 51 percent • Back pain – 49 percent • Diarrhea- 44 percent • Vomiting – 33 percent • Steatorrhea (fatty stools)– 25 percent • Thrombophlebitis – 3 percent
  18. 18. Signs of Pancreas Cancer • Jaundice (yellow) – 55 percent • Hepatomegaly (large liver) - 39 percent • Right upper quadrant mass – 15 percent • Cachexia (wasting) – 13 percent • Courvoisier’s sign (nontender but palpable distended gallbladder at the right costal margin) – 13 percent • Epigastric mass (fell lump in stomach) – 9 percent • Ascites (abdominal fluid) – 5 percent
  19. 19. Pathology Ductal adenocarcinoma accounts for about 85% of all neoplasms. And more than 95% of all pancreatic cancers arise from the exocrine (digestive enzymes) elements. Cancers that arise from the endocrine cells (neuroendocrine, islet cells) account for 5% or less
  20. 20. Parts of the Pancreas Portal Vein Aorta Superior Mesenteric Vein Head Body Tail
  21. 21. Cancer in the Head of the Pancreas Head Tail Body
  22. 22. Location of Pancreas Cancer • 60 to 70 percent of exocrine pancreatic cancers are localized to the head • 20 to 25 percent are in the body/tail and • the remainder involve the whole organ H = Head N = Neck B = Body T = Tail Un = Uncinate
  23. 23. Location of Pancreas Cancer • 60 to 70 percent of exocrine pancreatic cancers are localized to the head • 20 to 25 percent are in the body/tail and • the remainder involve the whole organ H = Head N = Neck B = Body T = Tail Un = Uncinate
  24. 24. Tests used to evaluate and stage pancreas cancer • Routine blood tests e.g. liver products like bilirubin • Elevated tumor markers (CA 19-9 or CEA) • MRI, CT scans, Ultrasound • Endoscopy including endoscopic ultrasound or ERCP • Laparoscopy • Biopsy
  25. 25. CA 19-9 The reported sensitivity and specificity rates of CA 19-9 for pancreatic cancer range from 70 to 92, and 68 to 92 percent, respectively. The rates of unresectable disease among all patients with a CA 19-9 level ≥130 units/mL versus <130 units/mL were 26 and 11 percent, respectively. Among patients with tumors in the body/tail of the pancreas, more than one-third of those who had a CA 19-9 level ≥130 units/mL had unresectable disease.
  26. 26. Elevated CA 19-9 Cancer - Pancreas - Biliary Cancer (gallbladder, cholangiocarcinoma, ampullary) - Hepatocellular - Gastric, ovarian, colorectal (less often) - Lung, breast, uterus (rare) Benign - Acute cholangitis - Cirrhosis and other cholestatic diseases (gall stones)
  27. 27. Ultrasound study of 900 patients who underwent ultrasound to work up painless jaundice, anorexia, or unexplained weight loss The sensitivity for detection of all tumors in the pancreas was 89 percent Among the 779 patients who were followed over time and established not to have developed a pancreatic tumor, nine had false-positive US findings (specificity 99 percent).
  28. 28. Ultrasound Mass in the pancreatic head and dilated common bile duct and pancreatic duct
  29. 29. CT Sensitivity of CT for pancreatic cancer depends on technique and is highest (89 to 97 percent) with triple-phase, helical multidetector row CT As expected, sensitivity is higher for larger tumors; in one study, the sensitivity was 100 percent for tumors >2 cm, but only 77 percent for tumors ≤2 cm in size
  30. 30. Endoscopy or ERCP or EUS
  31. 31. ERCP or Endoscopic retrograde cholangiopancreatography Scope Duodenum
  32. 32. ERCP Try to get into the duct system
  33. 33. ERCP Inject dye into the duct system and look for compression
  34. 34. ERCP Sensitivity of 92 percent and Specificity of 96 percent for diagnosing cancer of the pancreas by ERCP ERCP provides an opportunity to collect tissue samples (forceps biopsy, brush cytology) for histologic diagnosis. However, the sensitivity for detection of malignancy (approximately 50 to 60 percent) is lower than that of endoscopic ultrasound (EUS)-guided FNA (sensitivity 92 percent)
  35. 35. endoscope EUS (Endoscopic Ultrasound Ultrasound Tip Detailed image of this area
  36. 36. EUS or Endoscopic Ultrasound A: met to the pancreas head B: lymphoma in tail C: endocrine tumor in isthmus D: insulinoma in body From Endoscopic Ultrasound 2014:3
  37. 37. EUS used for pain relief with celiac plexus neurolysis
  38. 38. Endoscopic Placement of a Stent cancer stent duct pancreas stent scope
  39. 39. CT Scan – Pancreas Cancer
  40. 40. CT Scans
  41. 41. CT or PET Scan
  42. 42. PET Scans
  43. 43. TNM Stage: how far has the cancer spread, T (tumor) N (nodes) M (mets) combine all 3 to get Stage
  44. 44. Stage IA (T1aN0M0)
  45. 45. Stage IB (T2N0M0) over 2cm, limited to pancreas
  46. 46. Stage IIA (T3N0) beyond the pancreas
  47. 47. Stage IIB (T1-3N1M0)
  48. 48. Stage III (T4) Unresectable Cancer has spread to the major blood vessels near the pancreas. These include the superior mesenteric artery, celiac axis, common hepatic artery, and portal vein.
  49. 49. Stage IV - Metastasis Lung Liver Peritoneal Cavity Cancer in Pancreas
  50. 50. NCDB Statistics Stage Incidence Survival/5y I 8.5% 20% II 23% 10% III 14% 2.5% IV 54% 1.6%
  51. 51. 1.2 1 0.8 0.6 0.4 0.2 0 Survival by Stage 0 year 1 year 2 year 3 year 4 year 5 year Stage I Stage II Stage III Stage IV
  52. 52. Survival Surgery offers the only cure but only 10-20% are candidates for resection and even in this group the 5 year survival is only 20% and the median 13 to 20 months Locally advanced the survival is 8 to 14 months Up to 60% already have metastases and a median survival of only 4 to 6 months
  53. 53. nccn.org
  54. 54. nccn.org/patients
  55. 55. Summary of Treatment 1.Resection is the only chance for a cure, and resectable patients show undergo surgery without delay followed by adjuvant therapy 2.Borderline resectable patients may benefit from neoadjuvant therapy and then surgery 3.Unresectable patients may benefit from chemotherapy or chemoradiation 4.Metastatic disease may benefit from chemotherapy or other palliative treatments
  56. 56. Allen Oldfather Whipple (1881- 1963) Surgery professor at Columbia where he developed the resection for pancreas cancer in 1935 now called the Whipple Procedure
  57. 57. Summary of Treatment 1.Resection is the only chance for a cure, and resectable patients show undergo surgery without delay followed by adjuvant therapy 2.Borderline resectable patients may benefit from neoadjuvant therapy and then surgery 3.Unresectable patients may benefit from chemotherapy or chemoradiation 4.Metastatic disease may benefit from chemotherapy or other palliative treatments
  58. 58. Chemotherapy
  59. 59. Chemotherapy for Metastatic Pancreas Cancer • FOLFIRINOX (oxaliplatin (Eloxatin), irinotecan (Camptosar) , leucovorin, fluorouracil) • Gemzar (gemcitabine) + Abraxane (albumin bound paclitaxel) • Gemzar + erlotanib (Tarceva, EGFR drug)
  60. 60. Chemotherapy Survival Comparisons in Months 5-FU 4.4 Gemzar 5.6 Gemzar 6.8 FOLFIRINOX 11.1 Gemzar 6.7 Gem + Abraxane 8.7
  61. 61. Survival with Metastatic Pancreas Cancer FOLFIRINOX Months Gemzar NEJM 2011:364:1817
  62. 62. Survival with Metastatic Pancreas Cancer Gemzar + Abraxane Months Gemzar NEJM 2013;369:1691
  63. 63. Pancreas Cancer www.aboutcancer.com

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