Detailed Seminar on Carcinoma Pancreas with - Anatomy, Epidemiology, Enteropathogenesis, Pathology, Staging , Diagnostic workup and different modalities of Treatment

11. Ant. Surface- First part of duodenum,
Gastroduodenal A., Transverse colon, Jejunum.
Post. Surface- IVC , Renal vein, Rt. Crus of diaphragm & Bile
duct.

12. Constricted part b/w head and body.
Approx. 2cm wide.
Neck

22. • Neck and head :-into nodes along
pancreaticoduodenal, superior mesenteric
and hepatic arteries, & some also drain to
pre-aortic nodes & coeliac axis nodes.
• Tail and body:- into pancreaticosplenic
nodes, although some drain directly to pre-
aortic nodes.

24. *Role of para-aortic lymph node sampling in pancreatic cancer surgery.
Yusuke Kazami, Hiromichi Ito, Yoshihiro Ono, Takafumi Sato, Yosuke Inoue, and Yu Takahashi
Journal of Clinical Oncology 2020 38:4_suppl, 715-71

28. 12
7

30. SEER Data 2021

31. SEER Data 2021

32. SEER Data 2021

33. SEER Data 2021

34. SEER Data 2021

36. *Gaidhani, Rajshree & Balasubramaniam, Ganesh. (2020). An epidemiological review of pancreatic
cancer with special reference to India. Indian Journal of Medical Sciences. 73. 1-11.
10.25259/IJMS_92_2020.

37. *Gaidhani, Rajshree & Balasubramaniam, Ganesh. (2020). An epidemiological review of pancreatic
cancer with special reference to India. Indian Journal of Medical Sciences. 73. 1-11.
10.25259/IJMS_92_2020.

38. *Gaidhani, Rajshree & Balasubramaniam, Ganesh. (2020). An epidemiological review of pancreatic
cancer with special reference to India. Indian Journal of Medical Sciences. 73. 1-11.
10.25259/IJMS_92_2020.

41. *Lowery MA, Jordan EJ, Basturk O, et al. Real-time genomic profiling of pancreatic ductal adenocarcinoma: potential
actionability and correlation with clinical phenotype. Clin Cancer Res 2017;23(20):6094–6100

42. *Mandelker D, Zhang LY, Kemel Y, et al. Mutation detection in patients with advanced cancer by universal sequencing of
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45. *Humphris JL, Patch AM, Nones K, et al. Hypermutation in pancreatic cancer.
Gastroenterol 2017;152(1):68– 74.e2.

46. *(PanC4; http://www.panc4.org/).

47. *Wilentz RE, Goggins M, Redston M, et al. Genetic, immunohistochemical, and clinical features
of medullary carcinomas of the pancreas: a newly described and characterized entity. Am J
Pathol 2000;156(5):1641–1651.

48. *Reiter JG, Makohon-Moore AP, Gerold JM, et al. Reconstructing metastatic seeding patterns of
human cancers. Nat Commun 2017;8:14114

62. • Exocrine Malignant
• Pancreatic Ductal Adenoca
(PDA)
Less common Pancreatic Ca
• Acinic cell ca
• Pancreatoblastoma
• Intraductal Papillary
Mucinous Neoplasms
• Mucinous Cystic
Neoplasms
• Solid-Pseudopapillary
Neoplasms(Hamoudi or
Franz tumors)
• Exocrine Benign
• adenoma
• Cystadenoma
• Lipomas
• Fibromas
• Haemingoma
• Lymphangioma
• Neuromas
• Neuro endocrine
tumours
• Insulinoma
• Gastrinoma
• Glucagonoma
• Somatostatinoma
• VIPoma

65. *Caldas C, Hahn SA, Hruban RH, et al. Detection of K-ras mutations in the stool of patients with pancreatic
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67. *Kern SE, Kinzler KW, Bruskin A, et al. Identification of p53 as a sequence-specific DNA-binding
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83. *Kimura W, Kuroda A, Morioka Y. Clinical pathology of endocrine tumors of the pancreas. Analysis of
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84. Pancreatic Endocrine Neoplasms

85. *DeVita, Hellman, and Rosenberg’s Cancer Principles & Practice of Oncology 11th edition

86. *DeVita, Hellman, and Rosenberg’s Cancer Principles & Practice of Oncology 11th edition

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98. *Lemke AJ, et al. Retrospective digital image fusion of multidetector CT and 18F-FDG PET: clinical value in
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99. *NCCN Guidelines Version 2.2021 Pancreatic Adenocarcinoma

102. AJCC – 8th Edition

103. AJCC – 8th Edition

104. LN greater than 1 cm in
short axis or
morphologically abnormal
(e.g., are rounded, are
hypodense/heterogeneous/
necrotic, have irregular m
argins).

111. CT Slide showing case of Resectable CA Pancreas with no contact to SMA –
https://pubs.rsna.org/cms/10.1148/radiol.2019190422/asset/images/medium/radiol.
2019190422.va.gif

118. Pancreatic tumor invading aorta

120. CA Pancreas
Resectable Borderline resectable
Resection
Adjuvant treatment
Neoadjuvant chemo/RT
Unresectable
Chemotherapy/
chemoradiotherapy
Surveillance

122. *Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla of Vater.
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124. * Brozzetti S, et al. Surgical treatment of pancreatic head carcinoma in elderly patients. Arch Surg
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134. *Martin RC II, et al. Arterial and venous resection for pancreatic adenocarcinoma: operative and long-term
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135. *Tomlinson JS, et al. Accuracy of staging node-negative pancreas cancer: a potential quality
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136. *Diener MK, et al. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy
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137. Pylorus preserving pancreatico-duodenectomy
Facilitate controlled gastric emptying,
reduce intestinal transit time and
enhance intestinal absorption
Not indicated in patient with
Bulky tumors in pancreatic head,
Neoplasm involving first part of duodenum
 lesion associated with grossly positive pyloric
or peripyloric LNs.

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446.

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143. • Provides immediate therapy for subclinical metastasis
• initiation of local and systemic therapy shortly after diagnosis
rather than weeks following surgery

144. *Cameron JL, et al. Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer.
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adenocarcinoma: feasibility, treatment effect evaluation and prognostic factors, analysis of the
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147. *Stessin AM, Meyer JE, Sherr DL. Neoadjuvant radiation is associated with improved survival in
patients with resectable pancreatic cancer: an analysis of data from the surveillance,
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1133.

148. *Stessin AM, Meyer JE, Sherr DL. Neoadjuvant radiation is associated with improved survival in
patients with resectable pancreatic cancer: an analysis of data from the surveillance,
epidemiology, and end results (SEER) registry. Int J Radiat Oncol Biol Phys 2008;72(4):1128–
1133.

149. *Stessin AM, Meyer JE, Sherr DL. Neoadjuvant radiation is associated with improved survival in
patients with resectable pancreatic cancer: an analysis of data from the surveillance,
epidemiology, and end results (SEER) registry. Int J Radiat Oncol Biol Phys 2008;72(4):1128–
1133.

153. *Neuhaus P, et al. CONKO-001: final results of the randomized, prospective, multicenter phase III trial of adjuvant chemotherapy with
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154. *Neuhaus P, et al. CONKO-001: final results of the randomized, prospective, multicenter phase III trial of adjuvant chemotherapy with
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155. *Neoptolemos JP, et al. Adjuvant chemotherapy with fluorouracil plus folinic acid vs gemcitabine following
pancreatic cancer resection: a randomized controlled trial. JAMA 2010;304(10):1073–1081.

156. *Neoptolemos JP, et al. Adjuvant chemotherapy with fluorouracil plus folinic acid vs gemcitabine following
pancreatic cancer resection: a randomized controlled trial. JAMA 2010;304(10):1073–1081.

157. *Neoptolemos JP, Palmer DH, Ghaneh P, et al. Comparison of adjuvant gemcitabine and capecitabine with
gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label,
randomised, phase 3 trial. Lancet 2017;389:1011–1024.

158. *Neoptolemos JP, Palmer DH, Ghaneh P, et al. Comparison of adjuvant gemcitabine and capecitabine with
gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label,
randomised, phase 3 trial. Lancet 2017;389:1011–1024.

159. *Neoptolemos JP, Palmer DH, Ghaneh P, et al. Comparison of adjuvant gemcitabine and capecitabine with
gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label,
randomised, phase 3 trial. Lancet 2017;389:1011–1024.

177. *Versteijne E, Suker M, Groothuis K, et al. Preoperative chemoradiotherapy versus immediate surgery for
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178. *Le Scodan R, Mornex F, Girard N, et al. Preoperative chemoradiation in potentially resectable pancreatic adenocarcinoma:
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181. *Huguet F, Girard N, Guerche CS, et al. Chemoradiotherapy in the management of locally advanced pancreatic carcinoma: A
qualitative systematic review. J Clin Oncol 2009;27:2269-2277

184. Head of
pancreas
Body or tail
Superior
border
T10/T11 level (to
include celiac nodes)
Slightly higher
Inferior border L3/L4 level (depend
on pre-operative
imaging studies)
Same
Right border 2 cm right of pre-op
duodenum
same
Left border 2 cm from left
border of vertebral
body
More towards left
side to include
splenic hilum
AP-PA field borders :

185. Head of pancreas Body or tail
Superior border Same as AP-PA Same as AP-PA
Inferior border Same as AP-PA Same as AP-PA
Anterior margin 1.5-2 cm beyond gross
disease.
same
Posterior margin 1.5-2 cm of the anterior
portion of the vertebral
body (in the field) to
allow the margin on the
para-aortic nodes.
same

187. Parameters Head of pancreas Body or tail of
pancreas
Treatment volumes Pancreatico-duodenal,
suprapancreatic, celiac and
porta hepatis LN
+ entire duodenum +
2-3 cm beyond the gross
disease
Pancreatico-duodenal
and porta hepatis
nodes, lateral
suprapancreatic nodes
and nodes of splenic
hilum (± duodenal
loops) + 2-3 cm
margin beyond the
gross disease)

189. The post operative CTV should include:
Based on location of initial tumor from pre-operative imaging and pathology reports
Anastomoses - Pancreaticojejunostomy(PJ) , choledochal or hepaticojunostomy
Abdominal nodal regions – Peripancreatic , Celiac , Superior mesenteric , Porta hepatis , Para-aortic

192. Post op RT – Dose constrains

194. Normal Tissue Dose Limits

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Oncology 4(4): 343–351

203. *Wild AT, Hiniker SM, Chang DT, et al. (2013) Re-irradiation with stereotactic body radiation therapy as a novel treatment option for
isolated local recurrence of pancreatic cancer after multimodality therapy: Experience from two institutions. Journal of Gastrointestinal
Oncology 4(4): 343–351

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214. *Klinkenbijl JH, et al. Adjuvant radiotherapy and 5-fluorouracil after curative resection of cancer of
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215. *Klinkenbijl JH, et al. Adjuvant radiotherapy and 5-fluorouracil after curative resection of cancer of
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218. * Neoptolemos JP, et al. A randomized trial of chemoradiotherapy and chemotherapy after resection of
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219. * Neoptolemos JP, et al. A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic
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