Name
PANCREAS,CANCER
DESCRIPTION
DETAIL
CAUSES β’ No known etiology, though many associations β’ Association with chronic pancreatitis is controversial -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS β’ Choledocholithiasis β’ Pancreatitis β’ Pancreatic pseudocyst β’ Cholangiocarcinoma β’ Carcinoma of the ampulla of Vater β’ Duodenal neoplasms β’ Endocrine tumors of pancreas β’ Miscellaneous malignancies with extrinsic bile duct compression β’ Biliary tract stricture β’ Choledochal cystLABORATORY β’ Bilirubin level mean of 15 mg/dL (256.5 Γ¬mol/L) in patients with jaundice due to pancreatic cancer; considerably higher than that in patients with benign diseases (choledocholithiasis, strictures) β’ Patients with recent onset of jaundice with bilirubin greater than 10 mg/dL (171.0 Γ¬mol/L) should be considered to have neoplastic obstruction of common bile duct until proven otherwise β’ Alkaline phosphatase elevated in most patients. Mean of 550 U/L not signifi cantly different from level in patients with bile duct obstruction from benign disease β’ Anemia present in approximately 60% of patients β’ Stool occult blood present in approximately 90% of patients with periampullary tumors β’ Elevated amylase found in less than 5% of patients β’ Specific enzymes (gastrin, insulin) may be elevated when endocrine/islet cell tumor present β’ Tumor markers: β’ No tumor markers can be considered definitive in screening and detecting patients with pancreatic cancer. Is no single marker with excellent sensitivity and specificity. β’ CA 19-9 is primary marker used at present. Approximately 80% of patients with pancreatic cancer have serum CA 19-9 levels above 37 mcg/ml. Serum CA 19-9 is also elevated in patients with acute pancreatitis (30%), chronic pancreatitis (10%), biliary tract disease (20%) and chronic liver disease (20%). β’ Carcinoembryonic antigen (CEA) is elevated in about 50% of patients, the majority of whom are nonresectable for cure. SPECIAL TESTS Pancreatic juice - for cytology and CEA, CA 19-9 assays IMAGING β’ Some controversy as to best imaging option as accuracy varies with site and size of tumor β’ Helical CT scan: considered most useful imaging technique with sensitivity of 90% and specificity of 95%. β’ Abdominal ultrasound: useful initial screen in patients presenting with jaundice. Falling out of favor because not useful for staging and accuracy is operator dependent and limited by overlying bowel. β’ Endoscopic retrograde cholangiopancreatography (ERCP): Most useful in patients with suspected cancer in whom CT or US does not reveal a mass lesion within the pancreas and in those in whom the differential diagnosis includes chronic pancreatitis. Allows for biopsy, sampling of pancreatic juice and pancreatic duct cytology. β’ MRI/MRCP: Sensitivity/specificity similar to ERCP β’ Endoscopic ultrasonography: Is being increasingly studied as diagnostic tool. Appears useful in diagnosis of small tumors (<2-3 cm in diameter) and allows for fine needle aspiration of tissue during exam. Accuracy is operator dependent. * ERCP OR ENDOSCOPIC ULTRASONOGRAPHY * SELECTIVE & SUPER SELECTIVE ANGIOGRAPHY * SPIRAL CT SCANNING WITH CONTRAST IMAGING. *DIAGNOSTIC PROCEDURES . Biopsy: . CT-guided percutaneous needle aspiration has sensitivity of 85% with specifi city of approximately 100% in pancreatic adenocarcinoma. Few complications and extremely low risk of tract seeding. . Endoscopic ultrasound (EUS) guided fine needle biopsy gaining popularity for diagnosis/staging . Pseudocyst aspiration can differentiate benign pseudocysts from cystadenocarcinoma. Fluid in cystadenocarcinoma has low amylase, high CEA and lactate dehydrogenase (LDH) levels, and malignant cells are usually present. . Liver biopsy may be useful in patients with hepatic metastases . Laparoscopy/laparoscopy with ultrasonography with biopsy is becoming a popular technique and is likely to be more frequently used in the future for staging * OCTREOTIDE SCAN * PET SCAN
TYPENOTES
ABOUT 90% PACREATIC CARCINOMA PATIENT SHOW CHROMOSOMAL DEFECT RISK FACTORS :Probable: Race, diabetes mellitus, tobacco. Possible:Environmental / occupational exposures, dietary lipids, also is possible genetic predisposition in individuals withRISK FACTORS β’ Probable: Race, diabetes mellitus, tobacco β’ Possible: Environmental/occupational exposures, dietary lipids, also is possible genetic predisposition in individuals with chronic familial pancreatitis, Peutz-Jeghers syndrome and familial polyposis GENERAL MEASURES . Management highly variable and infl uenced by the overall health of the patient, presence of metastases, and location and size of tumor . Analgesia . Management of pruritus . Control of diabetes (usually brittle) if total pancreatectomy performed . Non-operative procedures . Biliary decompression by use of endoprostheses, transhepatic drainage catheters . Celiac blockade and epidural catheter placement for analgesia . Chemotherapy - multiple protocols . Radiation therapy - external beam (intraoperative - largely investigational) . Duodenal endoprosthesis for malignant duodenal obstruction SURGICAL MEASURES . Pancreaticoduodenectomy (Whipple procedure) . Total pancreatectomy . Regional pancreatectomy - resection pancreas, portal vein, regional nodes, subtotal gastrectomy . Biliary decompression for unresectable disease - Ttube, bilio-enteric anastomoses . Gastrojejunostomy for gastric outlet obstruction in unresectable disease DRUG(S) OF CHOICE β’ Analgesics β’ Management of pruritus, e.g., phenothiazines or cholestyramine β’ Chemotherapy - multiple protocols β’ Antacids β’ Pancreatic enzymes β’ Diabetes control PATIENT MONITORING Variable PREVENTION/AVOIDANCE Avoid tobacco POSSIBLE COMPLICATIONS β’ Pain β’ Jaundice β’ Malnutrition β’ Diabetes - especially in patients undergoing total pancreatectomy β’ Operative mortality - varies from 10-40% EXPECTED COURSE/PROGNOSIS β’ Overall 5 year survival rate is <5% given high likelihood of metastasis at time of diagnosis and is <1% if tumor is non-resectable at the time of diagnosis β’ Only treatment modality with potential for cure is surgical resection. Only 15-20% of patients are found to have potentially resectable disease at time of diagnosis. Annual survival for patients with resectable pancreatic cancer Resection Performed? 1yr 2yr 3yr Yes 48% 24% 17% No 23% 9% 6% ----------------------------------------------------- Notes: (1) 5yr survival rate if tumor is resectable & node negative, 25-30% (2) 5 yr survival rate if tumor is resectable and node positive, 10% (3) Median survival after resection, 18-20 months
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
STOOL FOR OCCULT BLOOD, FNAC, ULTRA SOUND WHOLE ABDOMEN - FEMALE, COMPLETE BLOOD COUNT, ERCP, CT SCAN ABDOMEN, MRI, BIOPSY, CA-19-9, CEA ( CARCINO-EMBRYONIC ANTIGEN )
CANCER
[PANCREAS,CANCER]
[HALAASANA]