Epidemiology, Definition, Types, Clinical Picture, Pathophysiology, Diagnostic Tools, Staging and Management (Medical/surgical/Nursing)

1. PANCREATIC CANCER
Presented by: Ms. Priyanka Malhotra,
M.Sc. Nursing 2nd year

2. LOCATION OF PANCREAS

3. Anatomy of Pancreas
Derived from ‘Pan’ – all ‘Kreas’ – flesh
15-20cm long, 2.5 – 3.8cm broad, 1.2 – 1.8cm thick
Weighs 80g
Situated in retro-peritoneum region
Head of pancreas (30%)- right side of the abdomen
(behind where the stomach meets the duodenum).
Body of pancreas (Body & Tail, 70%)- behind the
stomach.
Tail of the pancreas- left side of the abdomen next to
the spleen.

4. Head, Neck ,Body & Tail of Pancreas

5. Histology
80-90% of pancreatic tissue – Exocrine Acinar Tissue
organised as lobules
Pancreatic duct Interlobular & Intralobular ducts Ductules
Acini
Main duct – Columnar cells, Ductules – Cuboidal cells
Clusters of endocrine cells distributed throughout called
Islets of Langerhans
Islet: Hormone secretion
75% - B Cells- Insulin
20% - A Cells- Glucagon
5% - D Cells- Somatostatin

6. Posterior Relations Of Pancreas

7. Blood Supply, Lymphatics & Nerve Supply
Arterial: Pancreatic Branches of splenic artery
Superior pancreaticoduodenal artery
Inferior pancreaticoduodenal artery
Venous: Drains into splenic, superior mesenteric and portal
veins
Lymphatics: Head & Neck – Pancreaticoduodenal
Body & Tail – Pancreaticosplenic
Nerve Supply: Parasympathetic – Vagus
Sympathetic – plexuses around its arteries

8. BLOOD SUPPLY OF PANCREAS

9. Physiology
In response to food – secretes digestive enzymes in an alkaline
(bicarbonate) rich fluid.
Secretions enhanced by: Secretin, Cholecystokinin & Vagal
Stimulation.
Within cells enzymes are in inactive form.
Composition of Pancreatic secretions:
Electrolytes: Cations: Na+, K+, Ca2+, Mg2+, Zn2+
Anions: HCO3-, Cl- and traces of SO42-, HPO42
Enymes: Pancreatic alpha-amylase, Pancreatic lipase &
Pancreatic esterase
Proteolytic enymes: Trypsinogen, Chymotrypsin, Pro-
carboxypeptidase, Ribonuclease & Deoxy-ribonuclease.

11. EPIDEMIOLOGY
Estimated 278,684 cases of CA pancreas occur annually worldwide.
13th most common cancer globally.
Up to 60% of cases are diagnosed in developed countries.
Incidence is highest in the U.S., Western Europe and lowest in parts of
Africa and South Central Asia.
It is associated with poor survival and ranks as the 4th or 5th most
common cause of cancer mortality.
India-Incidence of CA pancreas is 0.5–2.4 per 100,000 men and
0.2–1.8 per 100,000 women.
(Thapa,P. (2015). Epidemiology of Pancreatic and Periampullary Cancer.)

12. CANCER OF THE PANCREAS
Cancer is caused by the abnormal and uncontrolled growth of
cells in the pancreas.
It may arise in any portion of the pancreas.
It can also be the site of metastasis from other tumors.
Clinical manifestations vary depending on the location of lesion.
CA Pancreas has only a 2-5% survival rate at 5 years regardless
of stage of disease at diagnosis.
Infiltrating ductal adenocarcinomas, account for the vast majority
of cases arising most frequently in the head of pancreas.

13. VARIOUS TYPES OF PANCREATIC CANCERS
1) Tumors of the Head of the Pancreas (75%)
Tumors producing the obstruction may arise from:
The pancreas, the common bile duct, or the Ampulla of Vater.
2) Exocrine pancreatic cancers (most common type)
• Pancreatic adenocarcinoma (90%): Starts in ducts of
pancreas.
• Acinar cell carcinomas: From pancreatic enzyme making cells.
• Less common types of exocrine cancer:
Adenosquamous carcinomas, squamous cell carcinomas, signet ring
cell carcinomas, undifferentiated carcinomas, and undifferentiated
carcinomas with giant cells.

16. VARIOUS TYPES OF PANCREATIC CANCERS
3) Pancreatic endocrine tumors or Islet Tumors
(neuroendocrine tumors-NETs)
Two types of tumors of pancreatic islet cells are known:
Insulinoma-Those that secrete insulin and
“Nonfunctioning” islet cell cancer-Those in which insulin secretion
is not increased.
4) Ampullary cancer (Carcinoma of the Ampulla of Vater)
They often block the bile duct, which leads to jaundice.
They are usually found earlier than most pancreatic cancers.
Therefore, have a better prognosis.

18. P
A
T
H
O
P
H
Y
S
I
O
L
O
G
Y

20. CLINICAL FEATURES
Physical Signs
• Jaundice, cachexia, and scratch marks.
• Courvoisier's sign: palpable gallbladder.
Distant metastases Physical signs:
• Hepatomegaly & Ascites
• Virchow's node -left supraclavicular lymphadenopathy and
• Sister Mary Joseph's nodes- periumbilical nodules.
Abdominal discomfort, pruritus, lethargy, weight loss, nausea and
vomiting .
Less common presenting features: New-onset diabetes
mellitus and acute pancreatitis.

22. DIAGNOSTIC EVALUATION
Physical Examination & History Collection
Diagnostic Imaging
Provides resectability and prognostic information.
Imaging modality of choice:
• Dual-phase, contrast-enhanced spiral CT
Accurate visualization of surrounding viscera, vessels and lymph
nodes.
• MRI (characterizes nature of small indeterminate liver lesions)
• Endoscopic retrograde cholangiopancreatography (ERCP)
It reveals small pancreatic lesions.

23. Coronal CT showing pancreatic cancer, dilated
intrahepatic and pancreatic ducts (arrows)

24. DIAGNOSTIC EVALUATION
• Magnetic resonance cholangiopancreatography (MRCP)
• EUS (highly sensitive in detecting lesions <3 cm size)
• Fluorodeoxyglucose positron emission tomography (FDG-PET)
 Tissue Diagnosis and Cytology
• EUS-guided fine-needle aspiration, Percutaneous biopsy
• ERCP- useful method for obtaining ductal brushings
 Serum Markers
• Tumor markers- CA 19.9, CEA, DU-PAN-2
• Tumor-associated CA19.9 is elevated (in 70-80%)
Preoperative CA19.9 1evels correlate with tumor stage and
Post-resection CA19.9 level has prognostic value.

26. ERCP showing contrast in dilated pancreatic
duct (arrows).

29. STAGING OF TUMOUR
American Joint Committee on Cancer (AJCC):
Tumor-node-metastasis (TNM) staging of pancreatic cancer.
It takes into account-
• The location and size of tumor,
• The involvement of lymph nodes and
• Distant metastasis.
From a practical standpoint, grouping is done as:
• Resectable,
• Locally advanced (unresectable, but without distant spread), or
• Metastatic (with distant spread).

35. TREATMENT OF PANCREATIC CANCER
Resectable Disease
Localized non-metastatic disease (10%) is best for surgical resection.
• Rl resection (microscopic residual disease)
• RO resection (no microscopic or macroscopic residual tumor)
Tumors of pancreatic head or uncinate process-
The standard surgical procedure is a pylorus-preserving
pancreaticoduodenectomy (modified Whipple's procedure).
• The common duct is sutured to end of jejunum, and
• The remaining portion of the pancreas and the end of stomach are
sutured to the side of jejunum.

37. Pancreatoduodenectomy
(Whipple’s procedure or resection)

38. VIDEO ON WHIPPLE’S PROCEDURE

39. TREATMENT OF PANCREATIC CANCER
For tumors of the pancreatic body and tail-
Distal pancreatectomy (includes splenectomy).
When tumor cannot be excised- To relieve jaundice
anastomosis of jejunum to gallbladder, known as
cholecystojejunostomy.
Adjuvant chemotherapy (6 cycles of gemcitabine).
Adjuvant radiotherapy (bulky tumors of pancreatic head).
• Metastatic Disease (60%)
5-FU/FA, irinotecan and oxaliplatin (FOLFIRINOX)
• Inoperable Locally Advanced Disease (30%)
Chemotherapy + consolidation radiotherapy

43. Studies of Adjuvant Chemotherapy in Resected Pancreatic Cancer
Study Comparator Arm No. of
patients
Survival
PFS/DFS (Months) Median Survival
(Months)
ESPAC-1， Neoptolemos
et al: N Engl J Med
350:1200,2004
Chemotherapy
(folinic acid + bolus
5-FU) vs no
chemotherapy
289 PFS 15.3 vs 9.4.
(p=0.02)
20.1 vs 155 (HR
0.71，95%CI 055-
0.92; P=0.009)
CONKO 001， Oettle et
al: JAMA 297:267,2007
Gemcitabine vs
observation
368 Median DFS 13.4 vs
6.9 (p<0.001)
22.1 vs 20.2
(p= 0.06)
ESPAC-3， Neoptolemos
et al: JAMA 304:1073，
2010
5-FU/LV vs
gemcitabine
1088 23 vs 23.6 (HR
0.94; 95% CI 0.81-
1.08，p=39)
Abbreviations: CI-Confidence Interval; CONKO- Charité Onkologie; DFS- Disease-free
survival; ESPAC- European Study Group for Pancreatic Cancer; 5-FU- 5-fluorouracil;
HR- Hazard ratio; LV- Leucovorin; PFS- Progression-free survival.

44. NURSING MANAGEMENT
Nursing Diagnosis for Pancreatic Cancer
Diagnosis 1: Chronic abdominal pain related to tumor growth
secondary to progressive pancreatic cancer.
Diagnosis 2: Imbalanced nutrition, less than body requirements,
related to anorexia, cachexia, malabsorption or nausea and vomiting
secondary to chemotherapy.
Diagnosis 3: Impaired skin integrity related to erythematous and wet
desquamation reactions to radiation therapy.
Diagnosis 4: Impaired tissue integrity related to alopecia secondry to
chemotherapy.

45. Nursing Diagnosis for Pancreatic Cancer
Diagnosis 5: Activity intolerance related to fatigue or weakness
secondary to chemotherapy or surgical intervention.
Diagnosis 6: Potential complications (risk for GI bleeding) related
to diseased condition.
Diagnosis 7: Risk for infection related to altered immunologic
response secondary to chemo-radiation therapy.
Diagnosis 8: Disturbed body image and situational low self-
esteem related to changes in appearance, function, and roles
secondary to surgical interventions (Whipple’s procedure).

46. Guidelines for perioperative care for
pancreaticoduodenectomy

49. Nursing Interventions
Pain management- Use of opioids or patient controlled
analgesia (PCA) for severe or escalating pain.
Nutritional and fluid requirements- To overcome anorexia
and profound weight loss.
Skin care- Use of Specialty mattresses and skin hygiene.
Teaching Patients Self-Care
Chemotherapy- Teaching on prevention of side effects and
complications of agents used.
Surgery- Management of drainage system and monitoring for
complications.
Continuing Care- Arrange palliative care (hospice services).

51. SUMMARY
The various topics discussed are as follows:
Location of the pancreas
Various types of pancreatic cancers
Risk factors for the pancreatic cancer
Clinical manifestations of pancreatic cancer
Diagnostic evaluation for pancreatic cancer
Treatment modalities for pancreatic cancer
Nursing management for pancreatic cancer

52. CONCLUSION
• Incidence of CA Pancreas has decreased slightly over past
25 years in non-Caucasian men.
• Diabetes mellitus, chronic pancreatitis, and hereditary
pancreatitis are associated with pancreatic cancer.
• Pancreas can also be site of metastasis from other tumors.
• In fact, pancreatic carcinoma has only a 2% to 5% survival
rate at 5 years regardless of stage of disease at diagnosis or
treatment.
• Patients should have surgery in dedicated pancreatic centers
that have lower postoperative morbidity and mortality rates.