Pancreatic cancer is the sixth leading cause of cancer death in the UK and the fourth leading cause in the US. It most commonly affects men over age 70. The majority (85%) are ductal adenocarcinomas that infiltrate locally and metastasize to the liver and peritoneum. Diagnosis involves imaging like CT scans and tumor marker tests. Surgical resection is the only potentially curative treatment but is only possible in 15-20% of cases due to late stage at presentation. Adjuvant chemotherapy may provide a survival benefit. Palliative options are aimed at relieving jaundice, gastric outlet obstruction, and pain. Prognosis remains poor with less than 5% of patients surviving 5

1. CARCINOMA OF THE
PANCREAS
DR. LALA ROBIN, MS. GEN. SURGERY,
CMC.

2.  sixth leading cause of cancer death in the UK and 4th leading cause in US.
 incidence is 10 cases per 100 000 population per year
 Men are affected slightly more commonly than women, with a 1.3 : 1
 The risk of pancreatic cancer increases with age beyond the sixth decade; the
mean age at diagnosis is 72 years.
 ninth most common cancer diagnosis
 Overall, less than 5% of individuals will survive 5 years beyond their diagnosis

5. Pathology
 Ductal adenocarcinoma
 85% of pancreatic cancers are ductal adenocarcinomas.
 solid, scirrhous tumours, characterised by neoplastic tubular glands within a markedly
desmoplastic fibrous stroma
 infiltrate locally, typically along nerve sheaths, along lymphatics and into blood
vessels
 Liver and peritoneal metastases
 Pancreatic intraepithelial neoplasia or PanIN - precede invasive ductal
adenocarcinoma

6.  Cystic tumours of the pancreas
 Serous cystadenomas
 mucinous cystic neoplasms (MCNs)
 intraductal papillary mucinous neoplasms (IPMNs)  Main Duct and Branch Duct
IPMNs.

7. Clinical features
 History
 Jaundice
 painless
 may be associated with nausea and epigastric discomfort
 Pruritus, dark urine and pale stools with steatorrhoea
 vague discomfort, anorexia and weight loss
 unexplained attack of pancreatitis
 Back pain - retroperitoneal infiltration

8.  Examination
 Jaundice
 palpable liver
 palpable gall bladder - Courvoisier sign (choledocholithiasis was commonly
associated with a shrunken fibrotic gallbladder, whereas the slow progressive
occlusion by other causes, including tumors, was more likely to result in ectasia of
the organ)

9. Investigation and Diagnostic Workup
 Laboratory Evaluation
 CBC
 RFT
 LFT
 coagulation profile
 nutritional assessment - prealbumin and albumin levels
 tumor markers - CEA, carbohydrate antigen 19-9 (CA 19-9), and α-fetoprotein

10.  Imaging Studies
 Ultrasound Abdomen will determine if the bile duct is dilated
 contrast-enhanced CT scan
 presence of hepatic or peritoneal metastases,
 lymph node metastases distant from the pancreatic head, or
 encasement of the superior mesenteric, hepatic or coeliac artery by tumour are clear
contraindications to surgical resection
 MRI and MR angiography can provide information comparable to CT

11.  Interventions
 ERCP and biliary stenting should be carried out if there is any suggestion of
cholangitis. It relieves the jaundice and can also provide a brush cytology or
biopsy specimen to confirm the diagnosis.
 EUS is useful if CT fails to demonstrate a tumour, if tissue diagnosis is required
prior to surgery (e.g. a mass has developed on a background of chronic
pancreatitis and a distinction needs to be made between inflammation and
neoplasia)
 Transduodenal or transgastric FNA or Trucut biopsy performed under EUS
guidance avoids spillage of tumour cells into the peritoneal cavity.
 Diagnostic laparoscopy prior to an attempt at resection can spare a proportion of
patients an unnecessary laparotomy by identifying small peritoneal and liver
metastases.

12. Surgical Management
 pylorus-preserving pancreatoduodenectomy (PPPD)
 This involves removal of the duodenum and the pancreatic head, including the distal
part of the bile duct.
 Classical Whipple procedure
 This involves removal of the gastric antrum, the duodenum and the pancreatic head,
including the distal part of the bile duct.
 Total pancreatectomy - multifocal tumour
 For tumours of the body and tail, distal pancreatectomy with splenectomy is the
standard

14. ADJUVANT CHEMOTHERAPY
 5-fluorouracil (5-FU)
 Gemcitabine
 gemcitabine with capecitabin

15. Palliation of pancreatic cancer
 Relieve jaundice and treat biliary sepsis
 ● Surgical biliary bypass
 ● Stent placed at ERCP or percutaneous transhepatic cholangiography
 Improve gastric emptying
 ● Surgical gastroenterostomy
 ● Duodenal stent

16.  Pain relief
 ● Stepwise escalation of analgesia
 ● Coeliac plexus block
 ● Transthoracic splanchnicectomy
 Symptom relief and quality of life
 ● Encourage normal activities
 ● Enzyme replacement for steatorrhoea
 ● Treat diabetes
 Consider chemotherapy

17. THANK YOU