This document discusses pancreatic cancer, including its incidence, risk factors, clinical presentation, investigations, staging, treatment options, and controversies in management. Some key points:
- Pancreatic cancer has a very poor prognosis with only 20% being operable and a 5-year survival of less than 5%.
- Risk factors include smoking, diet high in fat/low in fiber, diabetes, and certain occupations.
- Presentation is often vague with painless jaundice in 50-60% of cases. CT scan is the gold standard for staging and assessing operability.
- Surgical resection through pancreaticoduodenectomy or distal pancreatectomy offers the only chance of cure but is
Surgical management of pancreatic pseudocyst..by dr chris alumonaCHRIS ALUMONA
Pancreatic pseudocyst is the commonest cystic lesion of the pancreas but generally rare. It commonly complicates pancreatitis and resolves spontaneously with conservative management. Indications for intervention include complications and to rule out malignancy
This Presentation gives summarized overview of Gall Bladder Carcinoma especially the management as per latest National Comprehensive Cancer Network(NCCN) Guidelines version 2.2013
Surgical management of pancreatic pseudocyst..by dr chris alumonaCHRIS ALUMONA
Pancreatic pseudocyst is the commonest cystic lesion of the pancreas but generally rare. It commonly complicates pancreatitis and resolves spontaneously with conservative management. Indications for intervention include complications and to rule out malignancy
This Presentation gives summarized overview of Gall Bladder Carcinoma especially the management as per latest National Comprehensive Cancer Network(NCCN) Guidelines version 2.2013
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Pancreatic carcinoma is the most dreaded cancer with very dismal prognosis. It is characterized by obstructive jaundice, high colored urine and clay colored stool.
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Pancreatic carcinoma is the most dreaded cancer with very dismal prognosis. It is characterized by obstructive jaundice, high colored urine and clay colored stool.
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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2 Case Reports of Gastric Ultrasound
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
3. Why Pancreas is a nemesis
Anatomical relations
Potent enzymes
Difficult to anastamose
Access
4. Cuddles the L Kidney
Tickles the Spleen
Hugs the Duodenum
Cradles the Aorta
Dallies with R Renal pedicle
Wraps the SMA
Opposes the IVC
Hides behind the peritonium
6. Incidence
• Male : Female is 1.5:1
• Disease of old age. 80% of pancreatic
cancer occurs beyond the age of 60 years
• American Blacks-highest incidence (11-13
per 1,00,000)
7. Incidence
• In 2005, the American Cancer society
estimates that there will be approximately
32,180 new cases of pancreatic cancer in
the US, with 31,800 deaths
• Fourth most common cause of cancer
deaths
American cancer society. Cancer facts and figures
2005, Atlanta, GA
8. Ca Pancreas- The grim
situation
• Only 20% of pancreatic cancers are operable
for cure
• Only 10% - 15% of pancreatic cancers are alive
12 months after the diagnosis
• 5 year survival is less than 5%
• Average life of metastatic pancreatic cancer is 6
months
9. Etiology
• Cigarette smoking
• Diet – high fat and low fiber
• Diabetes
• Occupational
– benzidine
– naphthalimine
– Ethylene Dichloride
• Coffee – not proved
11. Is Chronic Pancreatitis premalignant
• The incidence of pancreatic cancer in
various entities of chronic Pancreatitis are
as follows
– Hereditary Pancreatitis 25%
– Tropical Pancreatitis 10%
– Alcoholic Pancreatitis 5%
15. Periampullary
carcinoma
• Any tumor within 2
cm from the duodenal
papilla is defined as
periampullary cancer.
Ca terminal PD
Distal CBD
Ampullary tumor
Duodenal tumor
18. Clinical presentation
• Mid epigastric pain radiating to back
• Weight loss
• Fatigue
• Anorexia
• Symptoms are vague and hence the
delayed presentation
19. Clinical presentation
• Painless progressive jaundice 50-60%
• Pruritus
• Staetorrhea
• Malabsorption
• New onset of Diabetes in older patients
20. Clinical presentation
• Jaundice is a late presentation in uncinate
process growth
• Severe back pain indicate irresectablity
and an omnious sign
26. CT
• “Pancreatic protocol CT” is the gold
standard of investigation to stage the
disease and assess the operability
– Triple phase CT
– Closer cuts
– Water used as an intraluminal contrast
– Helical or multislice
30. CT
• Advantages
– Available easily
– Surgeons are familiar with CT
– Excellent in giving details of operability
• Disadvantages
– May miss liver mets less than 1 cm
– Miss peritoneal mets
– Radiation
31. MRI
• Advantages
– No radiation
– Avoids contrast
– Single investigation that gives all the
information needed
• Disadvantages
– Cost & availability
– Surgeons are unfamiliar
34. Why not a biopsy
• May upstage the disease
• Complications of biopsy
• Has a very low negative predictive value
35. Role of Biopsy
• Tissue diagnosis is indicated in cases which
are found inoperable by imaging
• Biopsy is indicated when Neoadjuvant
chemotherapy is planned
36. What biopsy
• Ideally it should be
done under EUS
guidance
– Targeted
– No tumor seeding
– No complications
like fistula
37. ERCP
Double duct sign
Not routinely done in
pancreatic
Cancer
Preop biliary drainage
Atypical lower CBD
obstruction
38. PET
• It is useful in differentiating pancreatic
cancer from chronic Pancreatitis
• Extra pancreatic disease
39. EUS
• Ideal method to evaluate
lower CBD obstruction
• Guided FNAC
• Vascular invasion
• EUS+FNAC= sensitivity of
90% and specificity of 95%
43. Staging
• TX primary tumor cannot be assessed
• T0 no evidence of primary tumor
• T1 confined to pancreas
T1a less than 2 cm
T1b more than 2 cm
• T 2 tumor extend to involve the bile
duct, duodenum and peripancreatic
tissue
• T3 involvement of stomach, spleen, colon,
vessels
44. Staging
• NX nodes cannot
be assessed
• N0 no evidence
of nodes
• N1 regional
nodes present
• MX cannot be
assessed
• M0 no metastasis
• M1 distant
metastasis
45. Stage grouping
• Stage I
– T1 N0 M0
– T2 N0 M0
• Stage II
– T3 N0 M0
• Stage III
– Any T N1 M0
• Stage IV
– Any T Any N M1
54. Pancreaticoduodenectomy
• Walter Kausch was the first to successfully
perform pancreaticoduodenectomy in Berlin
1912
• Allen Whipple popularized the operation in
US in 1935
• Now this operation is called Kausch-
Whipple procedure
55. Pancreaticoduodenectomy
• This operation suffered a very bad
reputation due to the operative mortality of
over 25% and morbidity of over 50%
• Some authorities have even suggested that,
this operation be abandoned
57. What made whipple safe
• Better surgical technique
• Anaesthesia
• Improvement in postoperative care
• Concept of high volume center and
clinical pathways
63. Controversies
• Preop biliary drainage
• Preop imaging, CT vs. MR vs. EUS
• Role of biopsy
• Diagnostic laparoscopy
• PJ vs. PG
• Classical Whipple vs. PPPD
• Vascular resections
• Extended lymphadenectomy
• Drainage
64. Controversies
• Role of octreotide
• Order of reconstruction
• Adjuvant therapy
• Palliative resections
• Palliative bypass
65. Preop biliary drainage
• For
– Reduce the mortality and morbidity of surgery
– Improves the liver function
– Reduces the bleeding
– Improves the nutrition
– Buys time
66. Preop biliary drainage
• Against
– Does not reduce the mortality and morbidity
– More infectious complications
– It takes 6 weeks for the improvement of hepatic
microsomal functions
– Makes the duct small and fibrotic – adds to
technical difficulty
67. Preop biliary drainage
• Evidence
– Mc Pherson et al against
– Pitt et al against
– Hatfield et al against
– Lai et al against
– Lygitakis et al for
– Trede et al for
– Meta analysis against
68. Preop biliary drainage -
consensus
• Indicated
– Cholangitis
– Impending renal failure
– Surgery is likely to be delayed
– Bilirubin of more than 20 mg%
– Nutritionally very poor
– Neoadjuvant chemotherapy is planned
69. Preop biliary drainage -
consensus
Routine preop biliary
drainage is not
recommended and there is
no evidence to support it
70. Diagnostic laparoscopy
• 30% of patients found operable by imaging
are found to have small liver mets or
peritoneal mets, on diagnostic laparoscopy
Warshaw et al
71. Diagnostic laparoscopy
With the advent of high
quality CT, Helical and
Multislice, occult peritoneal
and liver metastasis are
documented in only 10% in
some series
72. PJ vs. PG
• Merits of PG
– Stomach is in proximity to pancreatic stump
– Better vascularity
– Acid in stomach inactivates enzymes
– Absence of enterokinase
– Even if leak occurs the enzymes are not
activated and hence fatal bleeding do not occur
73. PJ vs. PG
• Two randomized controlled trials fail to
demonstrate superiority of one method over
the other
• Dilated duct, texture of pancreas and
surgeon’s experience are more important
than the viscera used for drainage
74. Classical Vs PPPD
• PPPD is oncologically as radical as classical
whipple except for tumors encroaching on
the D1 and pylorus
• RCTs have failed to show any significant
benefit of PPPD over classical whipple
75. Vascular
involvement
• Resection of SMV is
accepted provide it
enables to perform R0
resections
• Involvement of SMA is
a contraindication for
resection
76. Extended
lymphadenectomy
• Studies have shown that
extended
lymphadenectomies can
be done with acceptable
morbidity
• Extended
lymphadenectomy do not
improve the survival
77. Octreotide
• There have been totally six RCT across the
Atlantic, three from Europe ( Buchler et al, Beger
et al , Pedrazolli et al) and three from US ( Yeo et
al, Sarr et al and Lowy et al)
• The European trials favor use of octreotide and the
American trials do not favor
• Recently published meta analysis of these trials
have shown a benefit of octreotide in reducing the
complications
79. Adjuvant therapy
• The ESPAC trial has shown that the only
factor that positively affect the long term
survival is administration of adjuvant
chemotherapy
• Ideally all patients undergoing surgery for
cancer pancreas should be given adjuvant
chemotherapy
82. Palliative bypass
• Options of by-pass
– Choledochojejunostomy ( Loop or Roux en Y)
– Cholecystojejunostomy
– Hepaticojejunostomy
83. Palliative bypass-prophylactic GJ
• The current recommendation is to perform
a prophylactic GJ along with the biliary
bypass even if there is no gastric outlet
obstruction
84. Laparoscopy in palliation
• Depending on the expertise of the surgeon,
procedures can be done with laparoscopy
85. Palliation of pain
• Neurolysis ( 20 ml of absolute alcohol
injected on either side of the celiac axis to
destroy the celiac ganglia)
– At laparotomy
– CT guided
– EUS guided
– Thoracoscopic splanchnectomy