Pancreatic Cancer The Killer that must be discovered early 27 th June - - PowerPoint PPT Presentation
Pancreatic Cancer The Killer that must be discovered early 27 th June 2015 Dr Alfred Kow Wei Chieh Consultant Department of Surgery Division of HPB Surgery & Liver Transplantation & Assistant Dean (Education) Yong Loo Lin School of
27th June 2015 Dr Alfred Kow Wei Chieh
Consultant Department of Surgery Division of HPB Surgery & Liver Transplantation & Assistant Dean (Education) Yong Loo Lin School of Medicine National University of Singapore
Epidemiology
Risk Factors
Clinical Presentation
Diagnosis
Treatment
Prognosis
Male Female
Colorectal, Breast and lung cancers in Singapore
mortality
and usually aggressive disease behaviour of the cancer
pancreatic CA:
– Blood stream – to liver, lung and bones – Lymphatics – to surrounding lymph nodes and remote lymph nodes eg neck LN – Direct invasion to surrounding structures eg vessels – Peritoneal lining (transcoelomic spread) – peritoneal nodules, ascites etc
heavy alcohol, residential radon exposure
Race/ Ethnic factors: African-American men & women,
Ashkenazi Jewish heritage
Known Inherited Genetic:
Familial pancreas CA, FAMMM, Hereditary pancreatitis, BRCA2, Peutz Jegher syndrome, von Hippel Lindau, Li-Fraumeni etc
High Risk Occupation: dry
cleaning, chemical plant, sawmills, uranium miners, electrical equipment manufacturing workers
Factors a/w Pancreatic CA
HIV, Hepatitis B, H Pylori infection, DM, pancreatitis,
Yeo et al Cancer J 2013
– Linear association of smokers with risk of developing pancreatic cancer. – Smokers 1 to 3X increase risk – Related to amount and duration of smoking – Risk persists beyond cessation of smoking
Family History and Inherited Genetic Disorders
– 5 to 10% of all pancreatic adenocarcinomas – hereditary – If familial PC – 1o family members – 9 X increased risk – If sporadic PC -- 1o family members -- 2 X increased risk – BRCA2 mutation family members – 6 to 19% increased risk – If familial PC – 3 or more family members affected – 57 X increased risk
Yeo et al Cancer J 2013
– DM is both a causal risk factor for pancreatic CA and a clinical manifestation of pancreatic CA inducing alterations in islet cell function and loss of β cell mass. – Hyperglycaemia or frank DM – 50 to 80% of patients with pancreatic CA. – Long term DM – at least 2 to 3 X increase in incidence of pancreatic CA – GDM – HR 7.06 (95% CI 1.69 – 29.45) compared to non- GDM cases (Israeli study 185,000 women over 14 years)
Sella et al Cancer Causes Control 2011
– Chronic pancreatitis – 3% of pancreatic CA
more than 6 drinks per day for 20 years
– Hereditary pancreatitis
– Usually begins in childhood or early adulthood – Is associated with a PRSS1 (7q35) mutation.
Lowenfels et al NEJM 1993
malignancy:
marker
Intraductal Papillary Mucinous Neoplasm
IPMN – 60%, branched-duct IPMN – 30%
nodules, size >3cm
Contact your doctor straight away!
Head of pancreas Jaundice, Tea coloured Urine, pale stool, itchiness
Body and tail of pancreas Back pain, LOW, localised left sided pain etc
– Tea coloured urine and pale stoool – Jaundice – Itchiness – Loss of weight, loss of appetite
Mann et al Eur J Surg Oncol 2000
– Dilated intrahepatic and extrahepatic bile ducts – Mass at head of pancreas (body and tail difficult to visualise) – Liver metastasis
– Confirm location of tumour – Invasion into surrounding structures – Invasion into vital vascular structures eg coeliac axis, SMA etc – Liver metastasis – Peritoneal metastasis – Lung metastasis
– The usual modalities are EUS-FNA (Endoscopic fine needle aspiration of pancreatic lesion)
– Ultrasound or CT guided percutaneous biopsy of liver lesion – Ultrasound aspiration of abdominal ascites for cytology
– Shows metabolic activity of the tumour – Extent of tumour metastasis
Pancreaticoduodenectomy (Whipple’s operation) for Head of pancreas tumour/ Uncinate process tumour
Distal/ Subtotal pancreatectomy for body or tail of pancreas tumour
Keyhole removal of distal pancreas
Surgical bypass (Double or triple bypass) for unresectable head
Endoscopic metal stent placement for unresectable head of pancreas cancer
Pancreatic Cancer Curative Rx Surgery Adjuvant chemotherapy Palliative Rx Biliary stenting Gastric outlet stenting Bypass surgery Pain management Symptomatic Rx
controversial
– Very selected patients who presented with borderline resectable tumours – may be able to undergo neoadjuvant chemoradiotherapy to downstage the tumour – If good response, can consider resection of the tumour at later time – Post-chemoRT R0 resection rate: 70.7% vs 59.7% (p<0.0001) with survival 20.5 months vs 9.5 months -- resectable
Gillen et al PLoS Med 2010.
present at resectable stage
process region
at the body and tail.
body and tail tends to be poorer as often presents with metastatic disease/advanced stage