| How is the epidemiology of pancreatic cancer? | Disease of aging, occurs after age of 45 usually, most important risk factor is cigarette smoking.
Other risk factors include other cancers (FAMMM, heriditary pancreatitis, breast cancer...) |
| How is the pathology of pancreatic cancer? | Ductal adenocarcinoma (85-90%) of pancreatic tumors.
70% in head (common bile duct affected causes jaundice, usually small tumor maybe resectable <3cm w/no metastasis), 5-10% body and 10-15% tail (stomach cause) |
| How is the invasion of pancreatic cancer? | Head tumors can obstruct common bile duct and pancreatic duct, leads to jaundice and chronic obstructive pancreatitis.
We see duct dilation, fibrous atrophy of pancreatic parenchyma.
Some tumors can involve ampulla of vater/ duodenum, and retroperitoneal tissue involvement is almost always present at time of dx can result in invasion of SMA and nerves/portal vein.
Neoplasms of tail can cause invasion of spleen, stomach, splenic flexure of colon or left adrenal gland, if advanced metastasis to lymph nodes, liver and peritoneum are common. Also pleura and lungs and bone are less commonly involved |
| What are the clinical symptoms of pt with unresectable (palliated) and resectable pancreatic cancer? | Paliated more severe abdominal pain and weight loss, while for resectable tumors we see more jaundice.
age almost same 65 years old, men more than women in both and mostly affects white race 91%. |
| How is the dx of pancreatic cancer done? | Imaging (not biopsy).
US (transabdominal frequently used (no one does it in lebanon))
CT (method of choice for dx, best one, limitation if tumor <2cm (not seen), tells extensions in early phases delineates the tumor and in late phases enhances vascular relationships and liver metastasis) sensitive 97%) |
| What does CT tells us regarding resectability? | Longstanding CT is done to see resectability, sees distant metastasis (liver...), encasement of celiac axis/SMA, occlusion of portal vein/SMV.
If tumor in tail/body usually easier to resect since no vessels are involved, while in head, bulb, duodenum and stomach are involved, so we remove them monoblock (all together) + remove SMA + SMV (which can be reconstructed)
10-15% are resectable, and 40% 5 year death. |
| What are the ERCP findings in case of pancreatic cancer? | Double duct sign (strictures in biliary and pancreatic ducts.
We can get tissue samples from ERCP (ampullomas, duodenal biopsy) by endoscopic forceps.
Tumors of distal bile duct maybe sampled by brush biopsy.
ERCP is unnecessary most of the time. |
| What is the significance of EUS in pancreatic cancer? | EUS most accurate but costly, but equally dx as CT (if not CT more after advances in it seeing vascularization and resectability)
Most sensitive method is EUS, and give ability to make FNA/FNB which is safe, reliable w/ no false-positive results (97% specificity).
EUS guided FNA proves malignancy and rules out other diseases (sarcoidosis/TB) and distinguish adenocarcinoma from other tumors (neuroendcrine/ lymphomas)
But usually we don't need biopsy for resection. |
| When do we use EUS? | Not necessary for all pt (if resectable by CT no need)
Stage IV disease, EUS-FNA is excellent option to dx primary tumors, and allows stratificetion of pt for resection vs neoadjuvant tx for borderline disease. |
| What is the dx use of CA 19-9? | Major tumor marker in presence of jaundice (cholangitis) but can give false-positive, and negative BGs can give false negatives as well.
Studies shown CA19-9 in pancreatic cancer in 85% (Cut off 37 U/ml), normalization of CA19-9 after resection and pt w/ CA19-9 above 90 didn't benefit from chemo |
| What is the significance of MRI in pancreatic cancer? | Not that much used, but can be useful in tumor evaluation,
MRCP non invasive |
| What is the use of PET-CT in pancreatic cancer? | No improvement in comparison with multidetector CT, assesses recurrence after resection, or benefit in assessing tumor response to neoadjuvant chemo |
| How is diagnostic workup of pt with pancreatic cancer? | Minimal workup include PE, CT/MRI of abdomen/pelvis.
Borderline cases use EUS w/CT.
For dx and staging, use laparoscopy for all pt w/ tumors in body and tail and pt w/tumors larger than 2cm in head |
| How is the staging of pancreatic cancer? | TNM
T: tumor (TX (not assessed), T0(no tumor), Tis (carcinoma in situ) T1 (limited to pancreas <2cm), T2 (limited to pancreas >2cm), T3 (beyond pancreas but not SMA/ celiac axis), T4 (invades all))
N (lymph node metastasis, NX(can't be assessed), N0 (no metastasisi) N1 (metastasis))
M (distant metastasis same as N)
Staging according to AJCC staging
Stage 0 (Tis, N0,M0), Stage IA (T1, N0,M0, Stage IB (T2, N0,M0), Stage IIA (T3, N0,M0), Stage IIB (T1/T2/T3, N1,M0), Stage III (T4, N1, M0), Stage IV (Any T, any N, M1) |
| What are the groups of patients in pancreatic cancer staging? | Group1 (metastatic, no surgery benefit, short survivial chemo)
Group2 (Locally advanced unresectable w/no metastasis, benefit chemo neoadjuvant and can be surgical after chemo)
Group3 (borderline resectable, more likely benefit neoadjuvant chemo)
Group4 (Resectable) |
| What are the indications of surgery for pancreatic cancer? | Only about 15-20% of pt are candidates to pancreatectomy (since mostly advanced disease stage)
Contraindications include encasement/ occlusion of SMV/portal vein, extension to celiac axis/SMA/vena cava.
Preop biliary stent is not recommended (if resectable) if non-resectable biliary stent is recommended as paliative tx. |
| How is prognosis after surgery of pancreatic cancer? | Poor prognosis, 5 year survival 25%, usually 12-24 months.
Surgery alone isn't enough, still needs immunotherapy/ molecular targetted therapy. |
| What is adjuvant and neoadjuvant chemotherapy of pancreatic cancer? | For 15-20% of resectable tumor pts, after surgery tx (may be alone or with chemoradiation) to prevent recurrence of distant pancreatic metastsis. |
| How is the treatment of distant metastatic disease? | Current recommendations include combination of Folfirnox or gemcitabine +nab-paclitaxel (if gemcitabine alone isn't effective) |
| How is the tx of unresectable/borderline pancreatic cancer? | Neoadjuvant chemo/ chemoradiation.
Typically chemoradiation for improvement for 11-12 months |
