Care of patient with pancreatic cancer

1. Case scenario
A 63-year-old Caucasian male was admitted to the hospital
from the emergency room with symptoms of epigastric pain
that radiated toward the back, abdominal distention,
vomiting, and jaundice
Laboratory tests:
• Bilirubin and liver enzymes; elevated
• CBC values WNL
• Hepatitis B, & C testing, negative
• CEA: 34.2 ng/mL; CA 19-9 > 12000 U/mL
• CT reveals 3.5 cm × 3.7 cm mass in the head of the
pancreas and multiple liver nodules; also, indicates an
obstruction of the bile duct.
• Diagnosis: stage IV pancreatic cancer with liver metastasis

2. Care of patient with Ca
Pancreas
Presenter:
Saumya P.Srivastava
Msc.nsg 2nd year
CON,AIIMS
Moderator:
Dr.L.Gopichandran
Lecturer
CON,AIIMS

3. Objectives
At the end of this session, you will be able to:
• To introduce the topic
• Explain epidemiology of pancreatic cancer
• Describe anatomy and physiology of pancreas
• Enumerate Etiology and risk factors associated with
pancreatic cancer.
• Explain Staging of pancreatic cancer
• Enlist Types of pancreatic cancer
• Explain pathogenesis of pancreatic cancer
• Describe clinical presentation of pancreatic cancer
• Enlist investigations
• Explain management(medical,surgical and nursing)

4. Introduction
• Pancreatic cancers can arise from the exocrine and
endocrine portions of the pancreas,93% of them
develop from the exocrine portion.
• Fourth leading cause of cancer deaths, being
responsible for 7% of all cancer-related deaths in
men and 8% in women.
• Approximately 75% of all pancreatic carcinomas
occur within the head or neck of the pancreas, 15-
20% occur in the body of the pancreas, and 5-10%
occur in the tail.
• It is a biologically aggressive tumor from the onset .
• Remains clinically queisent for a long time and
hence present in advanced state.

5. Location of pancreatic cancer

7. Epidemiology
• Pancreatic cancer is the ninth most common cancer in
women and the tenth most common cancer in men.
• The 5-year survival rate for people with pancreatic cancer
is 9%.
• The overall incidence rate of pancreatic cancer increased
by about 1% per year from 2006 to 2015.
• Incidence rates are 25% higher in black people than in
white people.
• Most pancreatic cancers (93%) are exocrine
adenocarcinoma

8. Cont..
• pancreatic cancer remains one of the most lethal
malignant neoplasms that caused 432,242 new
deaths in 2018 (GLOBOCAN 2018 estimates).
• Annual incidence 10 new cases per 100000
population.
• The American Cancer Society estimates that in the
United States in 2019, about 45,750 people (23,800
men and 21,950 women) will die of pancreatic
cancer.

9. Age and pancreatic cancer
Median age is 69 years in whites and
65 years in blacks

10. Anatomy Of Pancreas
• Pancreas is a long
retroperitoneal organ 15 to 20
cm in length.
• Weighs about 80 gms ,lies
against L1 & L2 Vertebra.
• It is arbitarily divided into
HEAD,NECK BODY & TAIL
• Head lies within the concavity of
duodenum against second
lumbar vertebra and body
overlies the first lumbar vertebra

11. Cont..
• The pancreas is made up of 2 types of glands:
 Exocrine
 Endocrine

12. Arterial and venous supply of
pancreas

13. Ducts of pancreas

14. Functions of the pancreas
The pancreas has digestive and hormonal functions:
• The enzymes secreted by the exocrine gland in the
pancreas help break down carbohydrates, fats,
proteins, and acids in the duodenum.
• The hormones secreted by the endocrine gland in
the pancreas are insulin and glucagon, which
regulate the level of glucose in the blood, and
somatostatin, which prevents the release of insulin
and glucagon.

15. Etiology and risk factors
• Older Age
• Male sex
• Heredity - cancer family syndromes
• Cigarette smoking
• Obesity
• Diet – high intake of red meat.
• Occupational
• Exposure to radiations
• Gastric surgeries
• Diabetes mellitus/pernicious anaemia/ chronic
Pancreatitis

16. Etiology-hereditary factors
• Hereditary pancreatitis
• Multiple endocrine neoplasia (MEN)
• Hereditary nonpolyposis rectal cancer (HNPCC)
• Familial adenomatous polyposis (FAP) and
Gardner syndrome
• Familial atypical multiple mole melanoma
(FAMMM) syndrome
• Hippel-Lindau syndrome (VHL), and germline
mutations in the BRCA1 and BRCA2 genes

17. Etiology – Diabetes – Is it a cause or
effect
• Several studies have shown an increased incidence
of pancreatic cancer in diabetics
• Diabetes is considered as an early symptom of
pancreatic cancer rather than being a cause
• The diabetes of Pancreatic cancer is due to islet cell
dysfunction (Islet Amyloid polypeptide) and not due
to the destruction of the gland

18. Types of pancreatic cancer
Exocrine tumors
• Pancreatic adenocarcinoma(85%)
Rare types:
• Adenosquamous
carcinomas
• Squamous cell carcinoma
• Signet ring cell carcinomas
• Undifferentiated carcinomas
• Undifferentiated carcinomas with
giant cells
• Pancretoblastoma
• Cystadenocarcinomas
• Colloid carcinomas

19. Benign and precancerous growths in the
pancreas
• Serous cystic neoplasms (SCNs)
• Mucinous cystic neoplasms (MCNs)
• Intraductal papillary mucinous neoplasms
(IPMNs)(most common of all)
• Solid pseudopapillary neoplasms (SPNs)

20. Pancreatic Neuroendocrine Tumors
(PNETs)
• About 7 percent of pancreatic tumors are
neuroendocrine tumors (pancreatic NETs or PNETs),
also called islet cell tumors. They often grow slower
than exocrine tumors.
• Pancreatic neuroendocrine tumors are either
functional (produce hormones) or nonfunctional (do
not produce hormones). Most PNETs are
nonfunctional

21. Pancreatic Neuroendocrine Tumors
(PNETs)
Common PNET types are:
• Gastrinoma (gastrin)
• Glucaganoma (glucagon)
• Insulinoma (insulin)
• Somatostatinoma (somatostatin)
• VIPoma (vasoactive intestinal peptide)
• Nonfunctional Islet Cell Tumor (no hormones)

22. Pathological (WHO) classification
• Primary ( 93% )
• Metastatic ( 7 % )
Duct cell origin – 90%
• Duct cell
adenocarcinoma – 75 %
• Mucinous carcinoma
• Cystadenocarcinoma
Acinar cell origin – 1%
• Acinar cell carcinoma
• Cystadenocarcinoma
( acinar cell )

23. Pathological (WHO) classification
Uncertain
histogenesis ( 9% )
• Pancreatoblastoma
• Papillary and cystic
neoplasm
• Mixed tumours
Connective tissue origin ( 1 % )
• Malignant fibrous histocytoma
• Osteogenic sarcoma
• Leiomyosarcoma
• Hemangio pericytoma

24. Pathogenesis

25. Staging of pancreatic cancer

26. Stage T1 pancreatic cancer

27. Stage T2 pancreatic cancer

28. Stage T3 pancreatic cancer

29. Stage T4 pancreatic cancer

30. Pancreatic cancer in nearby lymph
nodes – Stage N1

31. Pancreatic cancer metastasized – stage
M1

33. Clinical presentation
• Initial symptoms of the disease are often quite
nonspecific.
• Nonspecific symptoms such as anorexia, malaise,
nausea, fatigue, and midepigastric or back pain.
• Midepigastric pain , with radiation of the pain to the
midback or lower-back region.
• Weight loss
• Gastric outlet obstruction
• Delayed gastric emptying
• The onset of symptoms are insidious and
progressive
• Abdominal pain is usually post prandial
and in epigastrium

34. Tumors in the Head of pancreas
• Weight loss –
averaging about
40%
• Obstructive jaundice
• Deep seated
abdominal pain
• Non tender palpable
gall bladder
• Cholangitis occurs in
10 % of patients

35. Carcinoma of body and tail of pancreas
• Weight loss
• Deep seated pain
• Jaundice- < 10 % of
patient
• New onset of diabetes
mellitus-25% of
Patient
• Migratory
thrombophlebitis-
occurs in about10%
patient

36. Research Input
Diabetes and Pancreatic Cancer: Both Cause and
Effect Harvey A Risch
JNCI: Journal of the National Cancer Institute, Volume 111, Issue
1, January 2019
“About 25% of patients with pancreatic cancer have diabetes
mellitus at diagnosis, and roughly another 40% have pre-
diabetes,” that “patients with long-term (five or more years) type
II diabetes have a 50% increased risk of pancreatic cancer” and
“pancreatic cancer can cause diabetes, and sometimes diabetes
is an early sign of the tumor.”

37. Carcinoma of ampulla of vater
• Pain occurs less
frequently – usually its
colicky
• Jaundice is often
intermittent
• Chills and fever – due
to associated
cholangitis

39. Physical examination
• Pain radiating to the midback or lower-back region.
• Mild to moderate midepigastric tenderness.
• Palpable gallbladder (ie, Courvoisier sign)
• skin excoriations from unrelenting pruritus.
• Ascites
• Palpable abdominal mass
• Hepatomegaly from liver metastases
• Splenomegaly from portal vein obstruction
• Sister Mary Joseph nodule
• Blumer's shelf
• A metastatic node may be palpable behind the
medial end of the left clavicle (Virchow's node).

40. Differential diagnosis
• Acute Pancreatitis
• Cholangitis
• Cholecystitis
• Choledochal Cysts
• Chronic Pancreatitis
• Gallstones (Cholelithiasis)
• Gastric Cancer
• Peptic Ulcer Disease

41. Investigations
 Lab investigations
• CBC
• LFT
• RFT
• Coagulation profile
• CXR
• ECG
• Echo
 Imaging modalities:
• Computed tomography (CT)
• Transcutaneous ultrasonography (TUS)
• Endoscopic ultrasonography (EUS)
• Magnetic resonance imaging (MRI)
• Endoscopic retrograde
cholangiopancreatography (ERCP)
• Positron emission tomography (PET)
 Tumor Markers
• Carbohydrate antigen 19-9
• Carcinoembryonic antigen

42. Laboratory Findings
• Mild normochromic anemia
• Thrombocytosis
• In patients with obstructive jaundice:
bilirubin (conjugated and total)
alkaline phosphatase
gamma-glutamyl transpeptidase
aspartate aminotransferase
alanine aminotransferase
• Raised Serum amylase and/or lipase levels
• low serum albumin or cholesterol level in
patients with advanced pancreatic cancer.

43. Computed Tomography
• “Pancreatic protocol
CT” is the gold standard
of investigation to stage
the disease and assess
the operability.
• CT of the pancreas
requires specific IV
contrast agent protocols
to achieve optimal
contrast between normal
pancreatic tissue and
lesions.

44. Cont..
Includes:
• dual-phase CT acquisition
• IV contrast medium administration at a flow rate of
3–5 mL/s
• Helical or multislice
Advantages
• Available easily
• Surgeons are familiar with CT
• Excellent in giving details of operability
Disadvantages
• May miss liver mets less than 1 cm
• Miss peritoneal mets

45. Transcutaneous Ultrasonography
• As an initial screening test in evaluating patients
who present with possible obstructive jaundice.
• TUS has less utility in pancreatic carcinoma than
CT scanning.
• TUS can detect only 60-70% of pancreatic
carcinomas, more than 40% of the lesions smaller
than 3 cm are missed.

46. Endoscopic Ultrasonography
• It has proven to be the most sensitive and specific
diagnostic test for pancreatic cancer.
• Diagnostic advantage is EUS-guided fine-needle
aspiration.
• EUS as complementary to CT

47. Endoscopic Retrograde
Cholangiopancreatography
• Highly sensitive
• Usually reserved as a therapeutic procedure for
biliary obstruction.
• Brush cytology and forceps biopsy for histologically
diagnosing pancreatic cancer.
• Therapeutic palliation of obstructive jaundice through
stent placement

48. MRI
• The role of MRI in pancreatic cancer has been less well
studied.
• MRCP can be used as a noninvasive method for imaging
the biliary tree and pancreatic duct.

49. PET Scan
• Useful in detecting occult metastatic disease.
• False-positive PET scans have been reported in
pancreatitis.
• PET-CT scanning is more sensitive than conventional
imaging for the detection of pancreatic cancer.

50. Needle Aspiration
• EUS-guided fine-
needle aspiration
has proven to be the
most effective
means for making a
definitive cytologic
diagnosis of
pancreatic
carcinoma.

51. Treatment and management
• Resection is the only chance for a cure, and
resectable patients show undergo surgery without
delay followed by adjuvant therapy
• Borderline resectable patients may benefit from
neoadjuvant therapy and then surgery
• Unresectable patients may benefit from
chemotherapy or chemoradiation
• Metastatic disease may benefit from
chemotherapy or other palliative treatments

53. Treatment options
• Chemotherapy
• Adjuvant therapy
• Whipple procedure
• Distal pancreatectomy
• Total pancreatectomy
• Palliative therapy
• Dietary management

54. Chemotherapy
following drugs are approved by the US Food and
Drug Administration (FDA) for pancreatic cancer:
• Capecitabine (Xeloda)
• Erlotinib (Tarceva), a type of Targeted therapy (see
below)
• Fluorouracil (5-FU)
• Gemcitabine (Gemzar)
• Irinotecan (Camptosar)
• Leucovorin (Wellcovorin)
• Nab-paclitaxel (Abraxane)
• Nanoliposomal irinotecan (Onivyde)
• Oxaliplatin (Eloxatin)

55. Chemotherapy regimens
Adjuvant chemotherapy
• Gemcitabine 1000 mg/m2 IV over 30 min weekly for
3 wk; every 4 wk for six cycles.
• mFOLFIRINOX: Oxaliplatin 85 mg/m², leucovorin
400 mg/m², irinotecan 150 mg/m², 5-FU 2.4 g/m²
over 46 hours) every 14 days for 12 cycles.
Adjuvant chemotherapy and chemoradiation
• Concurrent chemoradiation starting 1-2 wk after
gemcitabine: 5-fluorouracil (FU) 250 mg/m2/day
continuous IV infusion via pump during radiation

56. Cont..
Treatment recommendations for locally advanced,
unresectable disease
• Gemcitabine 1000 mg/m2 IV over 30 min weekly for
3 wk; every 28 d.
• 5-FU 500 mg/m2/day IV bolus on days 1-3 and 29-
31 with concurrent radiotherapy, 40 Gy
Treatment recommendations for metastatic
disease
• Gemcitabine 1000 mg/m2 IV over 30 min weekly for
7 wk, followed by 1 wk off, then weekly for 3 wk;
every 28 d
• Gemcitabine 1000 mg/m2 IV weekly for 3 wk; every
28 d; plus capecitabine 1660 mg/m2/day weekly for
3 wk; every 28 d

57. Adjuvant therapy
• Adjuvant therapy with gemcitabine is accepted
as standard therapy for surgically resected
pancreatic cancer.
• Superior survival demonstrated with modified
FOLFIRINOX (mFOLFIRINOX)

58. Neoadjuvant therapy
Neoadjuvant therapy for patients with resectable or
borderline resectable tumor:
• FOLFIRINOX, with or without subsequent
chemoradiation
• Gemcitabine + albumin-bound paclitaxel, with or
without subsequent chemoradiation
• Gemcitabine + cisplatin (≥2–6 cycles) followed
by chemoradiation (only for
known BRCA1/2 mutations)

59. Complications related to
FOLFIRINOX
• Gastrointestinal toxicity
• Myelosuppression
• Infection
• Neuropathy
• Fatigue

60. Cont..
• In patients with unresectable locally advanced
pancreatic cancer, local ablation has been explored
as a treatment option.
• Radiofrequency ablation (RFA)
• Irreversible electroporation
• Stereotactic body radiation therapy (SBRT)
• High-intensity focused ultrasound (HIFU)
• Iodine-125
• Iodine-125–cryosurgery
• Photodynamic therapy
• Microwave ablation

61. Pancreaticoduodenectomy (Whipple
Procedure)
• It is a complex operation to remove the head of
the pancreas, the first part of the small intestine
(duodenum),antrum of stomach with surgical
drainage of the distal pancreatic duct and biliary
system, usually accomplished through
anastomosis to the jejunum
• It is the most often used surgery to treat pancreatic
cancer that's confined to the head of the pancreas.

62. Distal Pancreatectomy
• Distal pancreatectomy is a procedure in which the tail
and/or portion of the body of the pancreas are
removed, but not the head.
• Distal pancreatectomy may be an effective procedure
for tumors located in the body and tail of the pancreas.

63. Total Pancreatectomy
• The indication for the use of total pancreatectomy is
in cases in which the tumor involves the neck of the
pancreas.
• This can either be a situation in which the tumor
originates from the neck or is growing into the neck

64. Pancreatic transplantation
• Suitable donors between 20 and 50 yrs.
• Pancreatic blood flow to be maintained- warm
ischemia
• Gland should be perfused with a cold preservation
fluid hypertonic citrate solution
• Pancreas removed avoiding damage to the gland–
injection of collagenase enzyme into the pancreatic
duct under pressure.
• Pancreas transported to processing centre-within
four hours cold ischemia.

65. Complications related to surgery
• Pancreatic anastomotic leak
• Malabsorption
• Pancreatic stump leak
• Hemorrhage
• Endocrine insufficiency
• Insulin-dependent diabetes
• Delayed gastric emptying
• Intraabdominal abscess
• Biliary fistula
• Cholangitis
• Pancreatitis

66. Palliative Therapy
PAIN
 Narcotic analgesics
 Narcotic analgesics
with tricyclic
antidepressants
 Antiemetics
 Endoscopic
decompression with
stents.
JAUNDICE
 Endoscopic placement
of plastic or metal
stents.
 Biliary decompression
 choledochojejunostomy

67. Palliative Therapy
DUODENAL OBSTRUCTION
 gastrojejunostomy or an
endoscopic procedure.
 Endoscopic stenting of
duodenal obstruction

68. Dietary management
• Pancreatic enzyme replacement supplements.
• Eat little and often, aiming for a small meal or snack
every 2-3 hours.
• Eat more protein rich foods (meat, fish, eggs,
cheese, beans, lentils and pulses).
• Avoid Foods that contain lots of cheese,high fibre
foods, spicy foods.
• Choose carbohydrates with a lower glycaemic
index (GI).

69. Recent updates
• MR Based, Screening Program for Individuals at Risk
for Pancreas Cancer .
• Neoadjuvant Therapy for Pancreatic
Adenocarcinoma.
• Role of biopsy
• Preop biliary drainage
• Modified FOLFIRINOX (mFOLFIRINOX) also
provides significantly longer survival than gemcitabine
in patients with pancreatic ductal adenocarcinomas
who have undergone R0 or R1 resection.

70. Research Input
• Early Detection of Pancreatic Cancer: The Role of
Depression and Anxiety as a Precursor for Disease
Kenner, Barbara, J., PhD Pancreas: April 2018 -
Volume 47 - Issue 4 - p 363–367
Background: The depression-before-diagnosis relationship
is particularly notable in pancreatic cancer, which has very
few symptoms and frequently is a systemic disease at the
time of detection.
A review of the literature substantiates
that depression and anxiety may be potential precursors to
a pancreatic cancer diagnosis. Studies have started to look
more closely at this link, with an eye to developing a
testable marker for pancreatic cancer.

71. Cont..
• Conclusion: General practitioners and mental health
professionals need to be educated that these symptoms are
critically important when reported by an individual who has
not had depression or anxiety previously, is older than 50
years, and may be at high risk for pancreatic cancer (eg,
familial, new onset of diabetes).
• In those situations, referral to a mental health practitioner
who can further assess the patient may be as important as
providing a prescription that can help alleviate the
depression or anxiety.

72. Post-op management
• Hospital stays vary from 12 to 23 days, depending
on the seriousness of the intervention.
• The nasogastric tube (NGT) is required between
the POD 4 and 7.
• Assess for mild signs of infection, such as a
leukocytosis and fever during the first
postoperative week.
• Exogenous pancreatic enzymes.
• Regular blood glucose measurement is important
(approximately every 3 to 6 months).

73. Nursing management
• Acute pain related to obstruction of pancreatic, biliary ducts
possibly evidenced by reports of pain.
• Risk for deficient fluid volume related to excessive losses:
vomiting, gastric suctioning.
• Imbalanced Nutrition: Less Than Body Requirements related
to vomiting, decreased oral intake as evidenced by aversion
to eating,weight loss.
• Risk for Infection related to Inadequate primary defenses:
stasis of body fluids, altered peristalsis, change in pH of
secretion.
• Deficient Knowledge related to lack of exposure/recall,
unfamiliarity with information resources

74. Acute pain related to obstruction of
pancreatic, biliary ducts possibly evidenced
by reports of pain.
• Investigate verbal reports of pain, noting specific
location and intensity (0–10 scale).
• Note factors that aggravate and relieve pain.
• Maintain bedrest during acute attack. Provide quiet,
restful environment.
• Promote position of comfort on one side with knees
flexed, sitting up and leaning forward.
• Provide alternative comfort measures (back rub),
encourage relaxation techniques (guided imagery,
visualization), quiet diversional activities (TV, radio).

75. Cont..
• Administer medication as indicated:Narcotic
analgesics, sedatives, antispasmodics.
• Withhold food and fluid as indicated.
• Maintain gastric suction when used

76. Risk for deficient fluid volume related to
excessive losses: vomiting, gastric
suctioning
• Monitor BP and measure CVP if available.
• Measure I&O including vomiting, gastric aspirate,
diarrhea. Calculate 24-hr fluid balance.
• Note decrease in urine output (less than 400 mL per
24 hr).
• Note poor skin turgor, dry skin and mucous
membranes, reports of thirst.
• Investigate changes in sensorium (confusion, slowed
responses).
• Administer fluid replacement as indicated (saline
solutions, albumin, blood, blood products, dextran).

77. Cont..
• Monitor laboratory studies (Hb and Hct, Protein,
albumin, electrolytes, BUN, creatinine, urine
osmolality and sodium, potassium, coagulation
studies).

78. Imbalanced Nutrition: Less Than Body
Requirements related to vomiting, decreased oral
intake as evidenced by aversion to eating,weight
loss
• Assess abdomen, noting presence and character of
bowel sounds, abdominal distension, and reports of
nausea.
• Provide frequent oral care.
• Assist patient in selecting food and fluids that meet
nutritional needs and restrictions when diet is resumed.
• Note signs of increased thirst and urination or changes in
mentation and visual acuity.
• Maintain NPO status and gastric suctioning in acute
phase.
• Administer medications :Vitamins: A,D,E,K, Replacement
enzymes.

79. Risk for Infection related to Inadequate primary
defenses: stasis of body fluids, altered peristalsis,
change in pH of secretion.
• Use strict aseptic technique when changing surgical
dressings or working with IV lines, indwelling
catheters and tubes, drains.
• Stress importance of good handwashing.
• Observe rate and characteristics of respirations,
breath sounds. Note occurrence of cough and
sputum production.
• Fever and respiratory distress in conjunction with
jaundice.
• Obtain culture specimens (blood, wound, urine,
sputum, or pancreatic aspirate).
• Administer antibiotic therapy as indicated

80. Deficient Knowledge related to lack of
exposure/recall, unfamiliarity with information
resources
• Review specific cause of current episode and
prognosis.
• Explore availability of treatment programs and
rehabilitation of chemical dependency if indicated.
• Stress the importance of follow-up care, and review
symptoms that need to be reported immediately to
physician.
• Review importance of initially continuing bland, low-
fat diet with frequent small feedings.
• Instruct in use of pancreatic enzyme replacements
and bile salt therapy as indicated.

81. Take home message
• Pancreatic cancers can arise from the exocrine
and endocrine portions of the pancreas,93% of
them develop from the exocrine portion.
• Surgical resection if possible ,is the only curative
treatment but it can play a role only in very small
percentage of cases.
• Survival can be further increased by- early
detection.

82. References
• Bailey & love’s- short practise of Surgery
• CANCER PRINCIPLES- de vita
• Recent advances- wolters kluwer
• Itano, J. K., & Taoka, K. N. (Eds.). (2005). Core
curriculum for oncology nursing (4th ed.). St.
Louis: Elsevier/Saunders.
• Newton, S., Hickey, M., & Marrs, J. (Eds.).
(2009). Mosby’s oncology nursing advisor: A
comprehensive guide to clinical practice.
• https://www.cancer.gov/types/pancreatic

83. Thankyou