Pancreatic Cancer

1   Risk factors for  Pancreatic Cancer

An increased risk of pancreatic cancer has been associated with smoking, alcoholism, hereditary disorders [familial adenomatous polyposis (FAP), van Hippel-Lindau disease (VHL), hereditary breast cancer, Gardner syndrome], and chronic pancreatitis. The association with alcohol-induced pancreatitis is related to concurrent chronic pancreatitis and the well-established hypothesis that chronic inflammation is a predisposing factor for malignancy. Inherited pancreatic cancers represent approximately 5% to 10% of all diagnoses of the disease. Palladin is a recently identified gene found to be mutated in certain forms of familial pancreas cancer.

2  Pathology

Approximately 80% of pancreatic carcinomas are ductal cell adenocarcinomas. Seventy percent of pancreatic cancers occur at the head, 20% in the body, and 10% in the tail. Other periampullary tumors, such as carcinomas of the distal bile duct, duodenum, and ampulla of Vater, are less common and constitute approximately one third of resectable periampullary cancers.

3 How to Diagnosis?

The symptoms associated with pancreas cancer are almost always gradual in onset and are nonspecific.History and examination. Patients complain of dull midepigastric pain, malaise, nausea, fatigue, and weight loss. Classically, the report of new-onset “painless jaundice” is believed to be pancreas cancer until proven otherwise. Pruritus may accompany obstructive jaundice. If obstructive jaundice is present, patients for Pancreatic Cancer will also note darkening of the urine and “light-colored” stools. Finally, new-onset diabetes within the year prior to diagnosis is found in 15% of patients with pancreatic cancer. Jaundice, temporal wasting to suggest weight loss, and, in rare cases, a palpable abdominal mass all may result from pancreas cancer but are not universally present in patients with this disease. The so-called Courvoisier sign (painless jaundice with a palpable gallbladder) is an associated finding in patients with periampullary tumors and primary bile duct tumors. Trousseau’s sign (migratory thrombophlebitis) has been associated with pancreas cancer.

Laboratory tests.

Tumor markers. CA19-9 is useful in patients for whom the diagnosis is already highly likely as a means of confirmation and in follow-up for response to treatment, but it has no role in screening.

Radiologic studies

Ultrasonography forPancreatic Cancer is not as sensitive as CT and is limited by the presence of bowel gas. MRI  for Pancreatic Cancer may provide as much information as does CT but is costly, is limited in availability, and takes longer. Endoscopic ultrasonography can assess tumor size as well as portal and mesenteric vascular involvement and obtain tissue samples. Staging laparoscopy may be useful in identifying small liver metastasis and peritoneal implants.

4 What is the Treatment?

Surgical Curative resection

Surgery – Pancreatic Cancer from Cancer Council NSW on Vimeo.

Pancreaticoduodenectomy (Whipple procedure) for Pancreatic Cancer consists of en bloc resection of the head of the pancreas, distal common bile duct, duodenum, jejunum, and gastric antrum. Pylorus-sparing pancreaticoduodenectomy has been advocated by some, but there are no data demonstrating improved survival or lower morbidity. Extended lymphadenectomy, including nodes from the celiac axis to the iliac bifurcation and nodes from the portal vein and superior mesenteric artery, has not been shown to affect survival but does increase morbidity. There has been a sharp decline in morbidity and mortality in specialized centers, with a 30-day mortality of less than 5%.

Palliative treatment. for Pancreatic Cancer If the disease is considered unresectable at the time of surgery, palliative treatment must be considered. The goals are to offer prevention or relief from the three major problems that present in advanced metastatic pancreas cancer: (1) obstructive jaundice, (2) gastric outlet obstruction, and (3) pain.

Surgical palliation for obstructive jaundice and gastric outlet obstruction for Pancreatic Cancer is achieved by performing a biliary internal drainage procedure such as choledochojejunostomy and gastrojejunostomy. Incapacitating pain is a common complaint of patients at the end stages of their disease. Chemical splanchnicectomy can be preformed by instilling 50% ethyl alcohol in the celiac nerve plexus just adjacent the aorta at the level of the celiac artery.

Endoscopic biliary stenting can be used to temporize symptoms related to obstructive jaundice, and laparoscopic gastrojejunostomy tube placement has a possible role in patients with intestinal outlet obstructions. Endoscopic chemical splanchnicectomy can be done to help manage intractable pain.

Postoperative considerations. Delayed gastric emptying, pancreatic fistula, and wound infection are the three most common complications of the pancreaticoduodenectomy. Up to 10% of patients require a nasogastric tube for longer than 10 days, but delayed gastric emptying almost always subsides with conservative treatment. The incidence of delayed gastric emptying may be increased with pylorus-preserving procedures. The rate of pancreatic fistula has been demonstrated to be reduced to less than 2% by meticulous attention to the blood supply of the pancreaticoenteric duct-to-mucosa anastomosis

Radiotherapy and chemotherapy. The use of adjuvant therapy has been investigated in prospective fashion, and clear conclusions are not evident.

5  Results

Prognosis. Surgical resection can increase survival. Overall 5-year survival rates are 5% to 20% for patients after resection. In patients with small tumors, negative resection margins, and no evidence of nodal metastases, the 5-year survival rate is as high as 40%. Mean length of survival for unresectable locally advanced disease is 3 to 10 months, and for hepatic metastatic disease it is 6 months.