This document discusses carcinoma of the head of the pancreas. It begins with a case presentation of a 55-year-old female patient presenting with jaundice for 1 year and itching for 1 day. Her history and examination are provided. Imaging including CT scan revealed a mass in the head of the pancreas. The document then discusses pancreatic carcinoma, including risk factors, location, clinical features, investigations, staging, and management. Surgical options like the Whipple procedure are outlined as well as chemotherapy and palliative treatments. Multiple choice questions related to pancreatic cancer are also provided.

2. CARCINOMA OF HEAD OF PANCREAS
By
DR. DANISH RAUF
HOUSE OFFICER, CMH BAHAWALPUR
Supervisor
Col Malik Saeed Awan
Assistant Professor and HOD Surgery
Consultant General and Laparoscopic Surgeon
CMH BWP

3. CMH BWP
SEQUENCE
▪Case Presentation
▪Case Discussion

4. CASE PRESENTATION
CMH BWP

5. HISTORY
PATIENT PROFILE
• Name: XYZ
• Age: 55 years
• Gender: female
• Residence: Bahawalpur
• Date of presentation: 28 august , 2022
CMH BWP

6. PRESENTING COMPLAINTS
Jaundice-01 year Itching- 01 day
CMH BWP

7. HOPI
JAUNDICE
• My patient was in usual state of health 1 year back when she noticed
yellowing of her eyes.
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8. PRURITIS
Patient also had complain of
• Itching on whole body for last 2 months.
• It was increasing progressively.
• Relieved with medical ointment.

9. HOPI CONT
• Had poor appetite
• Loss of 1/3rd
of body weight in last 2 months
• Pale stools : last 1 year
• Dark yellow urine
There were no complaints of fever diarrhea or constipation

10. PAST HISTORY
• Medical hx:
DM Positive(7 Years)
• Personal History:
Poor Appetite
Poor Bowel Habits
• Drug History:
Oral medications for diabetes
• No hx of any drug or food allergies
• Positive Family History
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11. SYSTEMIC EXAMINATION
• GPE:
Well oriented in time place and person
Jaundice positive
• Vitals:
BP: 130/90 mmHg
Pulse: 92 bpm
SPO2: 97%
Temp: 98 degree F

12. SYSTEMIC EXAMINATION
• Respiratory:
• CVS:
• CNS:
• Musculoskeletal
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UNREMARKABLE

13. SYSTEMIC EXAMINATION
• Abdominal Examination:
• Inspection:
unremarkable
• Palpation:
GB palpable 2 fingers below the right coastal margin
No visceromegaly
• Auscultation:
BS normal

14. INVESTIGATIONS
All baselines
Blood CP:
TLC:11.9
Hb : 9.1
Plt : 385
Clotting Profile:
PT : 26
APTT: 48
Urine R/E:
Colour : deep yellow
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15. INVESTIGATIONS
LFTS:
•S.Total bilirubin : 245 (less than 17)
•S. ALT : 103 (UPTO 36)
•S. ALP : 1334 (LESS THAM 120)
•S. AMYLASE : 183
HEP B and C
Negative
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16. RADIOLOGICAL FINDINGS
• X-Ray: Normal study

17. • Ultrasound

18. CT SCAN

19. CARCINOMA HEAD
OF PANCREAS

20. ▶ Objectives:
▶ anatomy
▶ Epidemiology
▶ Clinical features
▶ Management

21. PANCREA
S

25. NORMAL
(50%)

26. CARCINOMA HEAD OF
PANCREAS
▶ Incidence is about 8 to 9 cases per 1,00,000
population.
▶ 74% of patients die within the first year after diagnosis,
with 5-year survival rate of only 6%.

27. RISK
FACTORS
▶ Environmental
▶ Genetic

28. RISK FACTORS – DEFINITIVE
ASSOCIATION
▶Smoking
1 – 3 times risk, Directly proportional to the
quantity and duration of smoking (i.e. pack
year).

29. Obesity

30. DIET

31. GENETIC RISK
FACTORS

32. LOCATION OF THE
TUMOUR
▶ About two-thirds of pancreatic adenocarcinomas
arise within the head or uncinate process of the
pancreas
▶ 15% are in the body
▶ 10% in the tail,
▶ remaining tumours demonstrating diffuse
involvement of the gland.

33. CLINICAL
FEATURES

34. ▶ TUMOURS IN THE HEAD OF THE
PANCREAS ARE TYPICALLY DIAGNOSED
EARLIER BECAUSE THEY CAUSE
OBSTRUCTIVE JAUNDICE.
▶ Tumours in the pancreatic body and tail are generally
larger at the time of diagnosis, and therefore, less
commonly resectable.

35. PRESENTATION -
HISTORY
▶ The classic constellation of symptoms in 66%-
75% of cases.
▶ Painless, progressive Jaundice associated with
▶ Pruritus
▶ Acholic stools
▶ High -coloured urine.
▶ Pain,( left sided tumour present with pain)
▶ cachexia

36. CLINICAL SIGNS

37. SIGNS OF ADVANCED
DISEASE
▶ Cachexia
▶ palpable nodules in the liver
▶ palpable metastatic disease in the left supra-
clavicular fossa (Virchow’s node),
▶ palpable metastatic disease in the periumbilical area
(Sister Mary Joseph’s node)
▶ Pelvic metastatic disease palpable anteriorly on
rectal examination (Blumer’s shelf).

38. VIRCHOWS NODE

39. SISTER MARY JOSEPH
NODES
Sister Mary Joseph’s node)

40. SISTER MARY JOSEPH

41. DR WILLIAM JAMES MAYO

42. BLUMMER SHELF

43. BIOCHEMICAL
INVESTIGATIONS
▶LFT
▶ Elevated bilirubin, alkaline phosphatase and GGT
▶ Only mild to moderate elevations in liver
transaminases

44. CA 19-9
▶ Used in cases where diagnosis is in doubt.
▶ Elevated in 75% of patients with pancreas cancer.
▶ also elevated in benign conditions of the pancreas,
liver, and bile ducts.
▶ To measure response to therapy or for screening for
recurrence
▶ Fallacy – can not be used in cases of jaundice.

45. IMAGING
▶ ultrasonography
▶ Computed tomography (CT),
▶ Endoscopic ultrasound (EUS)
▶ Magnetic resonance imaging (MRI) with or without
magnetic resonance cholangio-pancreatography (MRCP)
▶ Endoscopic retrograde cholangio-pancreatography
(ERCP)
▶ Positron emission Tomography (PET)

46. ULTRASONOGRAPHY

47. Dilated intrahepatic ducts. Double-duct sign” with dilated common bile duct and
pancreatic ducts.
CT SCAN

48. EUS

49. MRI images
with gadolinium contrast.

50. MRCP of patient with obstructive jaundice.

51. ERCP
▶ ERCP may be of benefit in patients with biliary
obstruction and cholangitis - endoscopic stent can be
placed for decompression.
▶ With current capabilities of CT and MRI, ERCP is
rarely necessary.

52. Endoscopic retrograde cholangiopancreatogram
(ERCP) of patient with pancreas cancer with abrupt
cut-off of main
pancreatic duct secondary to tumor.
ERCP of patient with pancreas cancer with
obstruction of both main pancreatic duct and common
bile duct

53. TISSUE DIAGNOSIS
▶ A tissue diagnosis of adenocarcinoma is not
required prior to an attempt at a curative
resection.
▶
▶ Does not change treatment decision in a
planned curative surgery.

54. FNA IS
REQUIRED IF
1. Patients undergoing neoadjuvant therapy.
2. If the diagnosis of carcinoma is uncertain.

55. STAGING
▶ CT, EUS, MRI to detect local disease.
▶ Chest x-ray with SOS CT chest,
▶ Staging laparoscopy- varies between institutions.

56. AJCC STAGING

57. STAGE
GROUPING

58. MANAGEMENT

59. Surgical Procedures
▶WHIPPLE PROCEDURE

60. ALLEN OLDFATHER
WHIPPLE
(1881-1963)
▶ Pancreatico-duodenectomy (PD)
was first performed by Kausch in
1908, and popularized by Whipple
in the 1930s (who performed 37
procedures).
—Whipple AO, Parsons WB,
Mullins CR.
Treatment of Carcinoma of the Ampulla of Vater.
Ann Surg 1935; 102: 763-769.

64. CHEMOTHERAPY
▶ 5 FU alone or combination with radiotherapy
▶ gemcitabine

65. PALLIATIVE TREATMENT
▶ Relief of Jaundice

66. • Relief Of Duodenal Obstruction

67. Relief of pain
1 ) Morphine
2 ) Chemical Ablation of Celiac Ganglia

68. MCQS
• The risk factors for pancreatic cancer includes all except:
A. Diabetes mellitus
B. Hereditary predisposition
C. Chronic pancreatitis
D. Smoking
E . Acute pancreatitis

69. ANSWER
E

70. The differential diagnosis of a mass lesion in pancreas includes all except:
• The differential diagnosis of a mass lesion in pancreas includes all except:
•
1. Lymphoma
2. Neuroendocrine tumour
3. Focal chronic pancreatitis
4. Autoimmune pancreatitis
5. None of the above

71. ANSWER
E

72. • A 65 year old gentleman presented with dull aching upper abdominal pain radiating
through to the back and worsened by eating. He had also noticed yellow discoloration of
his skin and had lost weight. In his past medical history, he was diagnosed with diabetes
mellitus 6 months earlier. A CT scan revealed a localised mass lesion in the head of
pancreas with biliary duct dilatation. All the following are true except:
•
A. CT guided biopsy is needed to confirm the diagnosis
B. A diagnosis of pancreatic cancer should be considered in unexplained diabetes (no family
history, obesity or steroids) in patients over 50 years of age.
C. Gastroduodenal artery encasement is not a contraindication for curative surgery
D. Whipple’s operation is the standard operation for cancer of pancreatic head

73. ANSWER
A