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Pancreatic Cancer
Cancer
25
Accounting
Pre-School
02/16/2011

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Cards

Term
Most common pancreatic neoplasm is
Definition
ductal adenocarcinoma (90% of pancreatic neoplasms)


Poorest survival rate of any major malignancy (5 year survival rate < 5%)
Term
% resectable, unresectable, metastatic
Definition
Resectable disease 15%

Locally advanced/unresectable disease 50%

Metastatic disease 35%
Term
Risk factors
Definition
Cigarette smoking
Hereditary pancreatitis
Chronic pancreatitis
Type II DM
Family history of pancreatic cancer (9%)
High fat intake
Exposure to non-chlorinated solvents and DDT
Term
what are signs of Early invasion of surrounding structures
Definition
CBD: obstructive jaundice
Duodenum: gastric outlet obstruction
Retroperitoneum: nerve invasion; pain = ominous sign!
Encasement of superior mesenteric vessels, celiac and/or hepatic artery and/or portal vein
Term
pathology:
Definition
Ductal phenotype
Extensive fibrotic reaction around tumor

Metastatic spread to regional lymph nodes and liver
Term
T/F: panc cancer is typically found before it has spread beyond the pancreas
Definition
F:
Patients often have extension of tumor
beyond the confines of the pancreas at
the time of presentation.
Term
Where in the panc are tumors usually located: % in tail, body, head?
Definition
Head 60-70%
Body 15%
Tail 10%
Term
Series of genetic events involving
activation of oncogenes and loss of tumor
suppressor genes
Definition
K-ras 85-90%
p16 80%
p53 60%
DPC4 50%
Term
PanIN3 vs PanIN2 lesions?
Definition
PanIN2 = p16, low grade dysplasia.
PanIN3 = P53/DPC4/BCRA2…high grade…these develop sequentially over time! NOT OVERNIGHT!
Term
Clinical presentation
Definition
Painless jaundice
Anorexia
Weight loss
Unexplained abdominal/back pain
Recent onset of non-insulin-dependent diabetes in the non-obese adult
Episode of unexplained pancreatitis – (obstructed duct)
Term
elderly
patient who presents with unexplained
pain, weight loss, or obstructive jaundice.
New presentation of diabetes in the
non-obese adult.

DDX?
Definition
PANC cancer
Term
T/F: the back pain in panc cancer is responsive to pain medicines
Definition
F: pancreas is tucked away and shielded
Term
Which tumor marker is frequently elevated in
pancreatic cancer, but is also elevated in
other GI malignancies, pancreatitis, hepatitis
and biliary obstruction.
What is the sens/spec of 15 U/ml, 37 U/ml, and 1000U/ml?
Definition
CA 19-9


sensitivity specificity
15 U/ml 92% 60%
37 U/ml 81-85% 81-90%
1000 U/ml 40% 99%
Term
What are other common lab elevations?
Definition
Liver function tests often reveal an elevated total and conjugated bilirubin level and alkaline phosphatase consistent with biliary obstruction
Term
T/F: US imaging is used primarily to detect the pancreatic head mass and the enzymes are the primary determinant of obstructive jaundice
Definition
F: US is the Initial test for obstructive jaundice
Determines level of biliary obstruction – combined intrahepatic and extrahepatic ductal dilation versus isolated intrahepatic ductal dilation
Evaluates CBD size
Determines if gallstones are present
Detects pancreatic head mass in only 40% of patients
Term
Why would you use an EUS over a CT scan?
Definition
Most accurate local staging modality (can identify lesions > 0.5 cm...vs. >1cm on CT (but CT tells you about metastases)
Very sensitive for evaluating local vascular involvement (although pancreatic protocol CT as good currently)
Useful in patients with underlying pancreatic disease who have abnormal appearing glands on CT scan
Can obtain FNA of mass for diagnosis
Term
Upon ERCP you see a double duct sign. What does this mean?
Definition
ERCP Useful for diagnosing cause of biliary obstruction when no mass is evident on CT scan or EUS
Therapeutic modality if appropriate for clinical scenario with stent placement
Brushing of pancreatic duct/CBD can be sent for cytology
Classic finding in pancreatic cancer on ERCP is the “double duct sign”
CBD left, panc duct supposed to converge here you have DILATIOn due to tumor blocking the converging site.
Term
Why would you put a panc canc px through surgery and what are outcomes like for head vs. body/tail lesions?
Definition
Only potentially curative therapy
Only 10-20% of patients are surgical candidates
Patients with head lesions – 15% are resectable
Patients with body/tail lesions – only 5% are resectable
Term
CT criteria for resection
Definition
No extrapancreatic disease
No extension/involvement of celiac and superior mesenteric arteries
Patent superior mesenteric and portal veins
Term
what is the surgery that is Used to treat cancer of the head of the pancreas (most cases of resectable tumors) and what does it involve?
Definition
The Whipple (pancreaticoduodenectomy)


Remove en bloc: b/c all shared blood supply
Pancreatic head
Duodenum
Distal CBD and gallbladder
Distal part of stomach
Term
QUIZ: When would you do a venous resection in panc cancer?
Definition
Venous resection should be considered when there was isolated tumor involvement of the SMV or portal vein without extension to the celiac or SMA
Term
T/F: Chemotherapy saves many lives in panc cancer since most px are not surgical candidates.
(Which agents are used?)
Definition
F:

Standard adjuvant therapy
Gemcitabine chemotherapy
Radiation therapy
Chemoradiation is not curative, but may extend life by several months
Neoadjuvant chemoradiation
Focus of clinical trials
Goal is to downstage patients with borderline resectable disease or questionable functional status
Term
All panc cancer outcomes:
Definition
Overall 5 year survival is < 5%
Survival in unresectable patients is 6 to 12 months
Survival in patients with metastatic disease is 6-8 months
“Curative” surgical resection 5 year survival is 20-25%
Term
Features of palliative care and what percent of the 85-90% of px with the incurable disease get these?
Definition
Biliary obstruction (80%)
Endoscopic options - metallic biliary wall stent
Operative options - choledochojejunostomy
Duodenal (gastric outlet) obstruction (25%)
Endoscopic options – duodenal stent
Operative gastrojejunostomy (gastric bypass)
Pain (80%)
Narcotics stop working
Chemical splanchnicectomy – “celiac block” most effective
Term
The road ahead for tx panc cancer?
Definition
Identify early detection biomarkers
Identify novel targets for therapeutics
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