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Presentation by Dr. Aziz Ahmad, Surgical Oncology, Mills-Peninsula Medical Center, April 23, 2011.
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Pancreatic Cancer
Aziz Ahmad, MDSurgical Oncology
Mills-Peninsula HospitalApril 23, 2011
Statistics
• 10th most common cancer – 4th leading cause of cancer death
Statistics
• 80% of cases are adenocarcinomas from exocrine pancreas– Less common exocrine tumors include:• IPMN• Mucinous cystadenocarcimomas
• Islet cell tumors• Insulin, glucagon, VIP, sandostatin, gastrin, nonsecreting
• Most common in black males• Median age of diagnosis is 70
Statistics
• Risk Factors:– Smoking– Low Vegtables & Fruits– High red meat– High sugar sweetened drinks– Chronic pancreatitis (especially hereditary)– Diabetes– Obesity– Genetic (5-10%)
• Family history, Puetz-Jerghers, HNPCC, FAP, Ataxia-Telangiectasia, Hereditary Pancreatitis, FAMMM-PC
Presentation
• Nonspecific symptoms– Tumors of body and tail
(25%)• Pain and weight loss
– Tumors of the Head (75%)• Jaundice, steatohrrea, weight
loss, Couvoirsier’s sign, pain
• Labs– Increased LFTs, elevated
CA19-9
Imaging• Ultrasound
– Bile duct distension– Mass
• CT scan with IV contrast– Quality of imaging continues to
improve– Triple phase CT (pancreas protocol)
90% accurate at finding lesions• Endoscopic ultrasound
– Help find lesions not seen on CT– Help determine resectability– Excellent way to get biopsy
• ERCP– Therapeutic as well as diagnostic
Treatment• Needs to be multimodal– Primary care, radiology,
gastroenterology, surgery, & oncology
• Surgery is the only cure– Cure only in those with
complete resections• Otherwise outcome is
poor with surgery
Treatment
• Finding lesions early (hardest job)– High index of suspicion by primary care
• Modern CT technology • Gastroenterologist with specialized skill in ERCP
and EUS• Surgeons with experience in pancreatic surgery• Radiation/medical oncology up to date with
standard of care and knowledge of any promising clinical trials
What is resectable?
• Tumors localized to pancreas – 15-20% of patients
• Locally advanced disease in patients with vascular involvement of less than 50% of portal vein
• Or lymph node spread that is limited – 10-15%– Resection contraindicated in patients:
• >50% involvement of portal vein• Invasion or encasement of SMA (or hepatic artery)
Non Surgical Candidates
• Palliative chemoradiation• Clinical trials– Median survival is about 8 months
• Palliative endoscopic or surgical procedures• 5-10% locally advanced patients not initially
surgical candidates can be downstaged
General Survival Data
• Overall prognosis seems dismal• 70-80% of patients present as inoperable due
to metastatic disease or locally advanced disease– Median survival only 4-6 months
• 20-30% are operable with localized or resectable locally advanced disease
• Successful operation can give five year survivals from 20-30%
Surgical Procedures
• Tumors of the Body and Tail– Laparoscopic distal
pancreatectomy• Removal of body &
tail of pancreas• spleen
Surgical Procedures• Head of the
pancreas: Whipple Procedure– Removal of:
• Distal stomach• Duodenum and
proximal jejunem• Head of pancreas• Gallbladder and
common bile duct
Complications
• Whipple Procedure– bleeding– Gastroparesis– Pancreatic duct leak– Bile duct leak– Diabetes– malabsorption
• Distal pancreatectomy– Bleeding– Pancreatic duct leak– Malabsorption– diabetes
Complications
• Particularly Whipple procedure thought to have poor surgical outcomes
• Mills-Peninsula experience in the last 40 Whipples:– 5% 60 day mortality
• Even in patients that recur after 2-3 years, quality of life is excellent before symptoms of disease return
Adjuvant Treatment
• Most patients go on to get adjuvant treatment– Gemcitibine based
chemotherapy– Radiation to the surgical
bed• Even with this 70-80% of
patients recur
Why Does it Recur?
• Pancreas with rich vascular and lymphatic supply– Early lymph node spread• Microscopic at the time of surgery
• Currently best chemo with only 25-30% response rate
Conclusion
• So at this time the best answer is to catch the disease early
• In those that you can detect disease early, all hope is not lost
• With an operation, you not only give a chance for cure, but you give hope