The document discusses pancreatic carcinoma, detailing a classical clinical vignette of a 72-year-old man presenting with jaundice, abdominal discomfort, and elevated bilirubin levels. It outlines the cancer's risk factors, pathology, clinical features, and current staging and treatment options, including surgical and palliative care methods. Additionally, it highlights the importance of early detection and the challenges of treatment due to the high recurrence and metastasis rates associated with this cancer.

1. PANCREATIC CARCINOMA
Dr.B.Selvaraj MS;Mch;FICS
Professor of surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
OBSTRUCTIVE JAUNDICE

2. Pancreas- Anatomy

3. Pancreas- Blood supply

4. Classical Clinical
Vignette
• 72 yrs old man presents with jaundice for 7days
with dull abdominal discomfort for 2 months. He
gives H/O loss of appetite and loss of weight.
• His stools have become lighter in color and his
urine is much darker than before
• He has a 50+ pack-year smoking history before
quitting last year
• He was recently diagnosed with type 2 diabetes,
but has no other medical problems

5. Classical Clinical
Vignette
• O/E: he has a yellow hue to his eyes and tongue,
along with scratch marks on his skin.
• A non-tender globular mass is palpated in the
right upper quadrant (RUQ) of the abdomen
• Labs: Laboratory testing reveals total and direct
bilirubin of 18 mg/dL (normal 0.2–1.3 mg/dL) and
17.2 mg/dL (<0.3 mg/dL), respectively.
• Alkaline phosphatase (ALP) elevated at 215 μ/L
(33–131 μ/L). AST & ALT mildly elevated

6. • 3rd
most common GIT cancer.
• 4th
most common cause of cancer death
• Death to incidence ratio is one.
( lowest among all types of cancer). why???
• Male:Female ratio 2:1
• Peak age 65 to 75 yrs
• Common in black americans
Introduction

7. Risk factors
• Cigarette smoking.
• Increased age.
• Chronic pancreatitis.
• Family H/O Pancreatic Cancer in more
than 2 first degree relatives
• Increased saturated fat intake.
• Exposure to non chlorinated solvents

8. Genetic Risk factors
• Chronic familial relapsing pancreatitis.
• Familial breast cancer ( BRCA2).
• Peutz –Jeghers syndrome.
• HNPCC (Hereditary non polyposis colorectal
cancer)
• Gardener syndrome.
• Familial atypical mole and melanoma
syndrome.

9. Genetic progression

10. Pathology
• Site :55% head of pancreas;25% body
15% tail; 5% periampulary
• Macroscopic : growth is hard & infiltrating
• Histology :90% ductal adeno ca;
9% cystic neoplasms
1% endocrine neoplasms
• Spread :Lymphatics to peritoneum & regional
nodes
Blood to liver & lung
Perineural spread Back pain

11. Clinical features
• Head&Periampulary : Painless progressive
jaundice with palpable GB- “Courvoisier’s Law”;
Vomiting due to duodenal block
Tea color urine, clay color stool & pruritus
• Body : back pain,anorexia,weight loss &
steatorrhea
• Tail : often presents with metastases,malignant
ascites or unexplained anemia

12. Investigations
• Lab : Elevated total & direct bilirubin
High Alk Phosphatase& GGT
Tumor marker CA19-9 >200U/ml
• USG Abd : can detect huge tumors
can’t pickup small mass
• MDCT : Triple phase CT abdomen: with arterial &
portal venous phase is sensitive to pickup
even small hypodense lesions

13. Investigations
• ERCP & MRCP : “Dual duct sign”
Therapeutic ERCP for palliative stent in CBD
& Duodenum
• Endoscopic Ultrasound:(EUS)
Excellent for staging the tumor
EUS guided pancreatic biopsy

14. CT Abdomen

15. ERCP “Dual Duct Sign”

16. Periampulary Mass
&EUS

17. Staging
Stage1 :Tumor is limited to pancreas with no
nodes or metastases
Stage2 :Tumor extends into bile duct,
peripancreatic tissues or duodenum. No nodes or
metastases
Stage3 :as stage 2 + positive nodes or celiac or
SMA involvement

18. Staging
Stage4a : Tumor extends to stomach,colon,spleen
or major vessels with any nodal status and
no distant metastases
Stage4b : Distant metastases with any nodal
status or tumor size

19. Staging & Prognosis

20. Treatment
• Rescectable tumors
• Borderline resectability
• Unresectable tumors

21. Resectable tumors
• Normal fat planes between tumor and
SMA, SMV
• Absence of extrapancreatic disease
• Patent SMPV confluence
• No direct extension to celiac axis or SMA

22. Borderline tumors
• Short segment occlusion of SMPV
confluence with an adequate vessel for
grafting
• Short segment (< 1 cm ) abutment of the
common or proper hepatic artery or SMA on
high quality CT

23. Unresectable tumors
• Extrapancreatic disease- distant metastases
• Encasement of coelic axis or SMA
( anything more than short
abutment)

24. Treatment Algorithm

25. Whipple’s Operation

26. Complications
• Delayed gastric emptying
• Pancreatic fistula
• Intra-abdominal abscess
• Operative site hge
• GI Hemorrhage

27. Palliative Surgery
• Biliary obstruction:
 Biliary enteric bypass
 Endoscopic biliary stent
placement
 Radiographic transhepatic
stent placement

28. Palliative Surgery
• Gastric outlet obstruction:
 Gastroenteric bypass
 Endoscopically placed
duodenal stent

29. Palliative Bypass

30. Adjuvant therapy
• 85% local recurrence .→ RT
• 70% liver metastasis.→CT
• 5 FU is the only active agent.
• Gemcitabine.
• 5 FU + Gemcitabine

32. Mindmap

33. Treatment Algorithm