Pancreatic cancer is sometimes called a "silent killer" because early pancreatic cancer often does not cause symptoms, and the later symptoms are usually nonspecific and varied. Therefore, pancreatic cancer is often not diagnosed until it is advanced.

1. CCaarrcciinnoommaa OOff TThhee PPaannccrreeaass
BByy
Dr. PARVIDER S. LUBANA
MS; D.N.B. FAMAS; FICS (USA)
• Fellow liver surgery Memorial Sloan Kattring Cancer Center, NEW YORK
• Fellow Colorectal Surgery Singapore General Hospital, SINGAPORE
• Fellow American College of Surgeons.
• Fellow European Digestive surgery.

2.  Pancreatic cancer is sometimes called a "silent
killer" because early pancreatic cancer often does
not cause symptoms, and the later symptoms are
usually nonspecific and varied. Therefore, pancreatic
cancer is often not diagnosed until it is advanced.

3. PANCREATIC NEOPLASM
 Benign or Malignant.
 Endocrine or Exocrine Tumor

4. BENIGN EXOCRINE TUMORS
 Most are cystic.
 Total incidence is 10-15% of all pancreatic tumors.
Serous cystadenoma
are purely benign without malignant potential, typically they are large
spherical masses that contain a watery fluid and have a central calcified
stellate scar, usually occurs in the body and tail region.
Mucinous tumors
Incidence:20-40%,highly malignant potential
Intraductal Papillary Mucinous Tumor
Rapidly increasing incidence with very high malignant potential and tendency
to become locally invasive and metastasize if left unresected.
Cure rate is low after development of invasive malignancy.

5. PANCREATIC NEOPLASM
 The most common type is ductal adenocarcinoma,
arises within the exocrine component seen in 85%
of all pan.ca..
 A minority (5%) arises from the islet cells and is
classified as a neuroendocrine tumor.
 Cystadenocarcinoma (1%) (Large cystic slow growing Tm)

6.  Pancreatic cancer often has a poor prognosis: for all
stages combined, the 1- and 5-year relative survival rates
are 25% and 6%, respectively;
 for local disease the 5-year survival is approximately
20%while the median survival for locally advanced and for
metastatic disease, which collectively represent over 80%
of individuals, is about 10 and 6 months respectively.

7. PANCREATIC ENDOCRINE TUMOR(PETS)
 PETs represent an important subset of pancreatic neoplasm.
 They a/c for 5% of all clinically detected Pan.Tm.
 They consist of single or multiple, benign or malignant neoplasm and are
asso. in 10-20-% of cases with MEN Type 1.
 Clinically PETs present as functional Tm, causing specific hormonal
syndrome or nonfunctional Tm with obstructive or pressure symptoms
similar to Pan.Ca.

8. FUNCTION OF ENDOCRINE PANCREAS
 Endocrine cells are found in Islets of Langerhans which constitute 1-2-%
of the total mass of the Pancreas.
 There are one million islets in a healthy adult Pancreas and there combine
weight is 1-1.5gms.
Four main types of cells…
 Beta cells producing Insulin(65-80% of Islet cells)
 Alpha cells producing Glucagon(15-20%)
 Delta cells producing Somatostatin(3-10%)
 Pancreatic polypeptide cells containing polypeptide(1%)

9. INSULINOMA
Insulin producing Tm ,causing Wipple”s Triad,i.e. symptom of hypoglycemia after
fasting or exercise, plasma glucose level less than2.8mmol/l and relief of
symptoms on I/V glucose.
 Insulinoma is m/c functioning PETs(70-80%)
 Seen in 4-6th decades in life with more common among females.
 90% are solitary and 10% are multiple and always asso. with MEN1 syndrome.
 Approximately 10% are malignant.
 Insulinoma of less than 2cm size without sign of vascular invasion or mets are
considered Benign..endoscopic ultrasound is investigation of choice

10. C/F:
features of Hypoglycemia; diplopia, blurred vision, confusion,
abnormal behavior and amnesia, lately LOC and Coma.
 The release of catecholamine's produces symptoms;
weakness, hunger,tremors,nausea, anxiaty and palpitation.
T/t- Surgical Excision of Insulinoma is the TOC.
 Medical m/m; Diazoxide supresses Insulin secretion by
direct action on beta cells, and for malignant Insulinoma
Doxorubucin and streptozocin combination chemotherapy
is applied for nonsurgical Tm

11. GASTRINOMA or Zollinger Ellision Syndrome(ZES)
ZES is a condition that includes;
(1) fulminating ulcer diathesis in the stomach, duodenum or atypical
sites;
(2) Recurrent ulceration despite adequate therapy and
(3)non-beta cell islet tm of pancreas(Gastrinoma)
 20% of all PETs
 0.1% of all duodenal ulcers.
 More in male.
 At diagnosis more than 60% are malignant.
 Mostly seen in head of Pancreas.
 More than 70% of Gastrinoma in MEN1 synd are located in first
and second part of duodenum

12. CLINICAL AND BIO CHEMICAL FEATURES
 Over 90% have peptic ulcer ds , often multiple or in unusual sites.
 Abdominal pain from either PUD or GERD remain the m/c symptom
seen in more than 75% pt.
 Diarrhea is caused by large volume of gastric acid secretion.
Biochemical diagnosis;
 Gastric pH below 2.5 and a serum gastrin concentration above 1000 pg
ml(normal less than100pg ml)
 EUS is gold standard to detect Gastrinoma.
 Most pan. gastrinoma are solitary an located in the head of the
pancreas.

13. Medical T/t;
PPI and Octreotide controls
hypersecration.
Surgical excision Enucleation with paripancreatic
lymph node dissection is procedure Of Choice.
systemic chemotherapy with Streptozotocin
with 5 FU is given for diffuse metastatic
Gastrinoma

14. CARCINOMA OF PANCREAS
 25000-30000 people diagnos each year in USA.
 Incidence is 10 cases per 100 000 population per year.
 Worldwide it constitute 2-3% of all cancers.
 Pancreatic cancer is the fourth most common cause of cancer
death both in the United States and internationally.
 Age. The risk of developing pancreatic cancer increases with age.
Most cases(80%) occur after age 60, while cases before age 40
are uncommon.
 Male sex (likelihood up to 30% greater than females)

15. RISK FACTORS :
5–10% of pancreatic cancer patients have a family history of pancreatic cancer,
two first degree relative with Pan.Ca -Relative risk increases 18-57folds.
 Chronic Pancreatitis (5-15-folds increased risk)
 Hereditary pancreatitis (50-70-folds increased risk)
 The risk with familial pancreatitis is particularly high.
 Chronic pancreatitis of any cause has been associated with a
25-year cumulative risk of 4%.
Mutation of the p-53 tumor suppressor gene is the m/c genetic event
in all human cancers and it is observed in 75% of pan ca.

16. Pan. Ca. is associated with the following
syndromes:
 Autosomal recessive ataxia-telangiectasia and autosomal
dominantly inherited mutations in the BRCA2 gene and
PALB2 gene,
 Peutz-Jeghers syndrome due to mutations in the STK11 tumor
suppressor gene,
 Hereditary non-polyposis colon cancer (Lynch syndrome),
 familial adenomatous polyposis, and the
 Familial atypical multiple mole melanoma-pancreatic
cancer syndrome (FAMMM-PC) due to mutations in the
CDKN2A tumor suppressor gene.

17. LIFE STYLE
 Cigarette smoking has a risk ratio of 1.74 with regard to
pancreatic cancer;
 Diets low in vegetables and fruits, high in red meat, high in
sugar-sweetened drinks (soft drinks)
 Diabetes mellitus is both risk factor for pancreatic cancer
and new onset diabetes in older age can be an early sign of
the disease.
 Obesity
 Helicobacter pylori infection
 Gingivitis or periodontal disease

18. PPATHOLOGY…
 75% -arise in the head, neck, or
uncinate process
 15%-originate in the body or tail
 20%-diffuse
 Typically, pancreatic cancer first metastasizes to regional
lymph nodes, and later to the liver and, less commonly, to
the lungs; it occasionally metastasizes to bone or brain.

19. Common symptoms depend on site of Tm include:
 Pain in the upper abdomen that typically radiates to the
back(seen in carcinoma of the body or tail of the pancreas)
 Loss of appetite and/or nausea and vomiting
 Significant weight loss
 Painless jaundice, pale-colored stool and steatorrhea.
 The jaundice may be associated with itching as the salt from
excess bile can cause skin irritation.
 Diabetes mellitus, or elevated blood sugar levels.

20. SSIGNS …
:In advanced cases
 Periumblical adenopathy ; Sister marry josef nodule.
 Enlarged left supraclavicular lymph node; Virchow's node
 Pelvic paritoneal deposits; Bulmer's shelf
 Trousseau sign, in which blood clots (thrombophlebitis) form spontaneously in the
portal blood vessels, the deep veins of the extremities, or the superficial veins anywhere
on the body, is sometimes associated with pancreatic cancer,
 Courvoisier sign defines the presence of jaundice and a painlessly distended gallbladder as
strongly indicative of pancreatic cancer, and may be used to distinguish pancreatic cancer
from gallstones.

21. INVESTIGATIONS…
 Blood test: Elevated S. bilirubin and Alk phosphatase
 Ultrasound Abdomen
 C T Scan abdomen
 MRCP
 ERCP
 PTC
 PET [newer]

22. USG ABDOMEN…
Heterogenous
pattern
with
medium sized
cysts

23. CC TT SSCCAANN ABDOMEN…

24. TUMOUR MARKERS…
 CEA
 Lewis blood group carbohydrate antigen CA 19-9 & CA 125
often normal in early potentially curable tm

25. STAGING……
 T1 limited to pancreas, 2cm or less in size.
 T2 limited to pancreas >2cm.
 T3 extends beyond pancreas, but not celiac or SMA.
 T4 involves celiac or SMA (unresectable).
 N0, N1
 M0, M1

26.  Stage 1 & 2 cancer are amenable to resection
 Stage 3 & 4 are considered to be unresectable
because of size, major arterial involvement

27. AIM OF STAGING…
to ……
Determine feasibility of surgical
resection and optimal treatment for each
individual patient.

28. RREESSEECCTTIIOONN OOFF PPAANNCCRREEAATTIICC CCAARRCCIINNOOMMAA……
 1912 :Kaush performed the first successful resection of duodenum and portion
of pancreas for ampullary cancer.
1935:Whipple-technique for radical excision of periampullary cancer
by pancreaticoduodenectomy followed by reconstruction by
 Pancretico-Jejunostomy (end to end or end to side)
 Hepatico-Jejunostomy (end to side)
 Gastro-Jejunostomy (anticolic end to side )
Feeding jejunostomy,

29. The standard resection for a Tm of the
Pancreatic head or th ampula is a PPPD-Pylorus
Preserving Pancreateo Duodenectomy,
it yield a more physiological outcome with no
difference in survival or recurrence rates.
For Tm of the body and tail, distal pancreatectomy with
spleenectomy is the standard.

30. KOCHERISATION…

31. DETERMINING RESECTABILITY…
Palpation of
Uncinate
Process,
Head of pancreas,
SMA.

36. RESECTED HEAD OF PANCREAS…

38. RE-ANASTOMOSIS…

39. PYLORUS PRESERVING….

40. POST OPERATIVE
SPECIMEN…

42. POST OPERATIVELY…
Complication rates remain high (15-20%).
 Pancreatic fistula remains the most frequent serious
complication (5-15%). The mortality from this has decreased
though(2-4%).
 Other common complications include
 delayed gastric emptying,
 abscess,
 bleeding,
 infection,
 diabetes,
 exocrine insufficiency.

43. 5 YEAR SURVIVAL….
 Stage 1 (T1-T2, N0, M0) 20-30%.
 Stage 2 (T3, N0,M0) 10-25%.
 Stage 3 (T4, any N, M0) 0-5%.
 Stage 4 (Any T, any N, M1) 0%.
Even after R0 resection 5 year survival rate is only 10-15%
 Very little or no role of RT+5FU & gemcitabine

46. Thanks …..