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- 1. Periampullary carcinoma –diagnosis with staging, preoperative preparation and management. DR. RAFI MOAZZAM 2ND YEAR JUNIOR RESIDENT
- 2. LABORATORY EVALUATION: BASIC LABORATORY TESTING INCLUDE: 1)CBC 2)Electrolytes 3) Liver Function Tests 4) Albumin 5) Prothrombin time SPECIAL LABORATORY TESTING: 1) CA19-9 SPECIFICITY And SENSITIVITY IS LIMITED And Poor PPV 72.3% ( Salvatore Scara’ et al.adv Exp Med biol.2015) don't make it a good cancer specific marker. Although with limitation CA19-9 continues being the only pancreatic marker. Not detected in Lewis A-B phenotype, falsely elevated in ongoing biliary obstruction, Other conditions such as inflammation, cholangitis, and nonpancreatic tumors (gastrointestinal, ovarian) are also associated with increased CA 19-9 levels
- 3. IMAGING EVALUATION: • A dedicated, fine-cut, 3phase pancreas protocol computed tomography (CT) scan. ARTERIAL PHASE (25 SEC) :HYPERVASCULAR NEUROENDOCINE TUMOURS ARE BETTER SEEN. PANCREATC PHASE(40 sec): Hypo vascular pancreatic adenocarcinoma are better appreciated. PORTAL VENOUS PHASE (70 SE): Vascular invasion liver mets are better seen. Why cect ? 1. Better delineation of pancreatic mass to vascular structures 2. Level of bile duct obstruction 3. Dilation of pancreatic duct 4. Regional lymph nodes 5. Liver or pelvic deposits 6. Presence of ascites 7. SN-86%
- 4. Axial and coronal computed tomography scans demonstrating a resectable tumor in the head of the pancreas (note plastic biliary stent) with clear tissue planes around the superior mesenteric artery and portal vein. Magnetic resonance cholangiopancreatography demonstrating an abrupt cutoff in the common bile duct from a tumor in the head of the pancreas. The pancreatic duct is also dilated, giving a strong suspicion of malignancy • In patients with CT contrast allergy- MRI with MRCP can be done. sensitivity of 84 %
- 5. • ENDOSCOPIC ULTRASONOGRAPHY: Small tumours > 2cm Relationship of the tumour to vasculature may well be seen Regional lymph nodes may also be seen FNAC can be done with decreased potential for peritoneal seeding compared to percutaneous biopsy The sensitivity of EUS-FNA for diagnosing pancreatic cancer is in the range of 80–95 %. Before initatiating NAT. Endoscopic ultrasound showing pancreatic mass with portal vein involvement.
- 6. ROLE OF ERCP VS MRCP: • MRCP is preoperative imaging procedure of choice to evaluate the pancreaticobiliary tree as it can evaluate the bile ducts both above and below a stricture (as opposed to ERCP) with no loss of sensitivity. • Distinguishes chronic focal pancreatitis with adenocarcinoma “duct penetrating sign” • Lesser morbidity (no radiation & no contrast) • ERCP helps in tissue diagnosis and biliary decompression in advanced as well borderline resectable cases undergoing NAT Focal pancreatitis demonstrating "duct penetrating" sign. Axial SSFSE T2w image shows a hypo- intense mass in the head of the pancreas (arrow) (a). The MRCP slab image shows a smooth continuity of the pancreatic duct (arrow) through the mass typical of the "duct penetrating sign" seen in focal pancreatitis (b).