Pancreatic cancer is the 10th most common cancer and the 4th leading cause of cancer death. 80% are adenocarcinomas from the exocrine pancreas. Risk factors include smoking, low fruit/vegetable intake, obesity, and family history. Symptoms are nonspecific but include jaundice, weight loss, and pain. Imaging like CT scans and endoscopic ultrasound are used to determine if tumors are resectable in 15-20% of patients. The Whipple procedure removes the pancreas head while distal pancreatectomy removes the body/tail. Adjuvant chemo may be given but 70-80% of patients still recur due to the pancreas' rich blood supply

1. Pancreatic Cancer Aziz Ahmad, MDSurgical OncologyMills-Peninsula HospitalApril 23, 2011

2. Statistics10th most common cancer 4th leading cause of cancer death

3. Statistics80% of cases are adenocarcinomas from exocrine pancreasLess common exocrine tumors include: IPMNMucinouscystadenocarcimomasIslet cell tumorsInsulin, glucagon, VIP, sandostatin, gastrin, nonsecretingMost common in black malesMedian age of diagnosis is 70

4. StatisticsRisk Factors:SmokingLow Vegtables & FruitsHigh red meatHigh sugar sweetened drinksChronic pancreatitis (especially hereditary)DiabetesObesityGenetic (5-10%)Family history, Puetz-Jerghers, HNPCC, FAP, Ataxia-Telangiectasia, Hereditary Pancreatitis, FAMMM-PC

5. PresentationNonspecific symptomsTumors of body and tail (25%)Pain and weight lossTumors of the Head (75%)Jaundice, steatohrrea, weight loss, Couvoirsier’s sign, painLabsIncreased LFTs, elevated CA19-9

6. ImagingUltrasoundBile duct distensionMass CT scan with IV contrastQuality of imaging continues to improveTriple phase CT (pancreas protocol) 90% accurate at finding lesionsEndoscopic ultrasoundHelp find lesions not seen on CTHelp determine resectabilityExcellent way to get biopsy ERCPTherapeutic as well as diagnostic

7. TreatmentNeeds to be multimodalPrimary care, radiology, gastroenterology, surgery, & oncologySurgery is the only cureCure only in those with complete resectionsOtherwise outcome is poor with surgery

8. TreatmentFinding lesions early (hardest job)High index of suspicion by primary careModern CT technology Gastroenterologist with specialized skill in ERCP and EUSSurgeons with experience in pancreatic surgeryRadiation/medical oncology up to date with standard of care and knowledge of any promising clinical trials

9. What is resectable?Tumors localized to pancreas 15-20% of patientsLocally advanced disease in patients with vascular involvement of less than 50% of portal vein Or lymph node spread that is limited 10-15%Resection contraindicated in patients:>50% involvement of portal veinInvasion or encasement of SMA (or hepatic artery)

10. Non Surgical CandidatesPalliative chemoradiationClinical trialsMedian survival is about 8 monthsPalliative endoscopic or surgical procedures5-10% locally advanced patients not initially surgical candidates can be downstaged

11. General Survival DataOverall prognosis seems dismal70-80% of patients present as inoperable due to metastatic disease or locally advanced diseaseMedian survival only 4-6 months20-30% are operable with localized or resectable locally advanced diseaseSuccessful operation can give five year survivals from 20-30%

12. Surgical ProceduresTumors of the Body and TailLaparoscopic distal pancreatectomyRemoval of body & tail of pancreasspleen

13. Surgical ProceduresHead of the pancreas: Whipple ProcedureRemoval of:Distal stomachDuodenum and proximal jejunemHead of pancreasGallbladder and common bile duct

14. ComplicationsWhipple ProcedurebleedingGastroparesisPancreatic duct leakBile duct leakDiabetesmalabsorptionDistal pancreatectomyBleedingPancreatic duct leakMalabsorptiondiabetes

15. ComplicationsParticularly Whipple procedure thought to have poor surgical outcomesMills-Peninsula experience in the last 40 Whipples: 5% 60 day mortalityEven in patients that recur after 2-3 years, quality of life is excellent before symptoms of disease return

16. Adjuvant TreatmentMost patients go on to get adjuvant treatmentGemcitibine based chemotherapyRadiation to the surgical bedEven with this 70-80% of patients recur

17. Why Does it Recur?Pancreas with rich vascular and lymphatic supplyEarly lymph node spreadMicroscopic at the time of surgeryCurrently best chemo with only 25-30% response rate

18. ConclusionSo at this time the best answer is to catch the disease earlyIn those that you can detect disease early, all hope is not lostWith an operation, you not only give a chance for cure, but you give hope