Carcinoma Pancreas

Risk Factors: (a) Demographic factors: -men -Blacks -60 to 80 yrs -Jews (b) Host factors: Heriditary Pancreatic Cancer syndromes-> -Heriditary Nonpolyposis colon cancer (HNPCC) -Familial Breast cancer (BRCA 2 mutation) -Peutz-Jegher's syndrome -Familial atypical multiple mole melanoma (FAMMM) syndrome -Ataxia Telangiectasia -Heriditary Pancreatitis (c) Environmental: -Tobacco Pathology: Ductal adenocarcinoma - 80-90% 70% - in pancreatic head or Uncinate process a halo of chronic pancreatitis surrounds the tumour areas of vascular & lymphatic invasion Perineural growth of the tumour Variants of Ductal adenocarcinoma --> mucinous noncystic carcinoma (colloid carcinoma), signet ring cell carcinoma, adenosquamous carcinoma, anaplastic carcinoma, giant cell carcinoma & sarcomatoid carcinoma Others --> acinous cell carcinoma, Pancreatoblastoma, Leimyosarcoma, liposarcoma, plasmacytomas & lymphaomas Development & molecular biology: codon 12 mutation of K-ras oncogene (GTP dependent event) mutation of p53 tumour suppresssor gene p16, SMAD-4, DPC, DCC Retinoblastoma gene, Adenomatous Polyposis Coli (APC) gene overexpression of EGF (Epidermal Growth Factor) HER2/neu overexpression alteration in p16 --> PanIN-2, PanIN-3

Symptoms & signs: - insidious tumours - new-onset Diabetis Mellitus - may be the 1st symptom of occult cancer

Frequent

Infrequent

Pancreatic Head Cancer: weight loss pain jaundice dark urine light stools anorexia Pancreatic body/tail cancers: weight loss pain weakness nausea anorexia vomiting jaundice dark urine light stool pruritus Nausea weakness pruritus vomiting

- Unexplained migratory thrombophlebitis (Trousseau's syndrome) --> paraneoplastic phenomenon (tumour induced hypercoagulable state) - Liver nodules - Metastatic subumblical ("Sister Mary Joseph" nodules) - pelvic metastasis encircling perirectal region ("Blummer's shelf") - Left supraclavicular lymphadenopathy ("Virchow's nodes") - malignant ascitis - splenic/portal/superior mesentric vein occlusion -> oesophageal varices, caput medusae palpable gall bladder with painless jaundice (Courvoisier's sign) special features: -sunburst pattern of calcification -Reverse 3 sign of Frostberg TNM staging: - UICC T1 - limited to pancreas T2 - Extension directly to dudenum, bile duct or peripancreatic tissues T3 - Extension directly to stomach, spleen, colon, or adjacent large vessels N0 - no nodes N1 - nodal metastasis M0 - no distant metastasis M1 - Distant metastasis Stage Stage Stage Stage 5 year survival I T1,T2 N0 M0 II T3 N0 M0 III anyT N1 M0 IV anyt anyN M0 20-40% 10-25% 10-15% 0-8%

Investigations:

Blood tests: [ Bilirubin & ALP [ CEA [ Lewis blood group carbohydrate antigen CA 19-9 (cutoff value 37U/ml) Imaging studies: Transcutaneous USG-hypoechoic mass lesion with irregular margins -"cuff" sign Helical contrast enhanced CT-hypodense mass, poorly demarcated margins -central necrosis or cystic damage -panceatic duct to the left of lesion may be dilated MRI PET ERCP - superimposed bile duct & pancreatic duct strictures ("Double-Duct" sign) - "scrambled egg appearance" Hypotonic duodenography Petcutaneous Transhepatic Cholangiography - PTC indication: dialated duct system Oral cholecystogram Barium - widening of C-loop - Reverse 3 sign of Frostberg (periampullary carcinoma) Biopsy: percutaneous biopsy -> CT/USG guided transduodenal biopsy -> endoscopic USG guided Triple test of Lundh - 1. Pancreatic function tests 2. Cytology 3. Hepertonic duodenography HIDA scan [ Hepatic immuno diacetic acid ] indication : for post operative bile leak Laparotomy - to assess operability by 'two finger test' Signs of inoperability: 1.vascular invasion 2.Ascitis 3.Liver secondaries 4.posterior fixity of tumour

Treatment: 1. Whipple's surgery 2. PPPD --> pylorus preserving pancreatico Duodenectomy structures removed in Whipple's surgery: 1.Head of pancreas 2.C-loop of duodenum 3.Distal half of stomach 4.Gallbladder along with cystic duct & CBD Restoring anastamosis --> Triple anastamosis 1. Gastojejunostomy 2. Pancreaticojejunostomy 3. Hepaticojejunostomy If inoperable --> palliative treatment - treat jaundice - if ascitis --> endoscopic stenting - if no ascitis --> Palliative gastrojejunostomy + Cholecystojejunostomy + jejunojejunostomy - if malignant ascitis --> instill radioactive phosphorous or 5-FU or mitomycin into peritoneal cavity