ca pancreas please go through it useful for both ug and pg

1. Carcinoma Head of
pancreas
CHAIRPERSON
DR. JAGADISH B
PROFESSOR AND HOD
DEPT. OF GENERAL SURGERY
KVG MEDICAL COLLEGE
PRESENTER
Dr. Veeranath reddy.v
PG Student

2.  Referrences:
 Bailey &love 26th edition
 Schwartz principles of surgery (10th edition)
 Sabiston first (southeast asia edition)
 Blumgarts hepatobiliary surgery

3.  Objectives:
 Surgical anatomy
 Epidemiology
 pathology
 Clinical features
 Management

4. Pancreas

9. Normal (50%)

10. Carcinoma head of pancreas
 Incidence is about 8 to 9 cases per 1,00,000
population.
 9th most common cancer in the US , but 4th in terms of
cancer deaths.
 74% of patients die within the first year after diagnosis,
with 5-year survival rate of only 6%.

11. Risk Factors
 Environmental
 Genetic

12. Risk Factors – Definitive Association
Smoking
1 – 3 times risk, Directly proportional to the
quantity and duration of smoking (i.e. pack
year).

13. Environmental risk Factors –
Suggested Association
 Diabetes Mellitus
 Chronic Pancreatitis
 Obesity
 Diet

14. Diabetes Mellitus
 Glucose intolerance in 80% of patients , 50%
overt diabetes.
 Two fold increase in chance of Ca pancreas in
patients with pre existing diabetes.
 The new onset of diabetes - may be an early
manifestation of occult pancreatic cancer.

15. Chronic Pancreatitis
 Patients with chronic pancreatitis especially
familial have up to a 20-fold increase in risk for
pancreatic cancer.

16. Obesity
 obese patients may be up to three times more likely
to develop pancreatic cancer than non-obese
individuals.

17. Diet
 Increased risk with increased total calorie intake, and
increased intake of carbohydrate, cholesterol, meat, salt,
dehydrated food, fried food, refined sugar, and nitrosamines.
 Fat, beta carotene, and coffee are of unproven risk.
 Consumption of dietary fibre, vitamin C, fruits, vegetables, and
unprepared food may have a protective effect, as may
pressure and microwave cooking.

18. Environmental risk Factors – Unproven
Association
 Alcohol
 Coffee
 Radiation

19. Genetic Risk Factors

20. Pathology
 Pancreatic cancer probably arises through a stepwise
progression of cellular changes.
 From Pancreatic intra epithelial neoplasia to invasive adeno
carcinoma.
 75% are ductal adenocarcinoma
 Uncommon varieties include Adeno squamous and Acinar cell
carcinoma.

21. Pancreatic Intraepithelial Neoplasia
(PanIN)
 Pre cursor lesions for invasive carcinoma
 Three stages of pancreatic intraepithelial neoplasia have been
defined. From PanIN 1 – PanIN 3
 With progressive cellular atypia and architectural disarray.

23. Location of the tumour
 About two-thirds of pancreatic adenocarcinomas
arise within the head or uncinate process of the
pancreas
 15% are in the body
 10% in the tail,
 remaining tumours demonstrating diffuse
involvement of the gland.

24. Clinical features
 The symptoms at presentation are related to the
location of the tumour.
 Lesions occurring in or near the bile duct presents
with obstructive jaundice,
 body or tail with pain.
 Weight loss, loss of appetite, generalised weakness -
non specific

25.  Tumours in the head of the pancreas are typically
diagnosed earlier because they cause obstructive
jaundice.
 Tumours in the pancreatic body and tail are generally
larger at the time of diagnosis, and therefore, less
commonly resectable.

26. Presentation - History
 The classic constellation of symptoms in 66%-
75% of cases.
 Painless, progressive Jaundice associated with
 Pruritus
 Acholic stools
 High -coloured urine.
 Pain,( left sided tumour present with pain)
 cachexia

27.  Pancreatitis in the absence of cholelithiasis and ethanol
abuse.
 New onset diabetes mellitus and pancreatic exocrine
insufficiency are rare as initial presentation.
 Non specific symptoms include nausea, anorexia, weight
loss.
 Symptoms of GOO – Indicate locally advanced disease.

28. Clinical signs
 Anaemia
 icterus,
 hepatomegaly,
 a palpable gallbladder (Courvoisier’s sign),
 and skin excoriation from pruritus and scratching.

29. Signs of advanced disease
 Cachexia
 palpable nodules in the liver
 palpable metastatic disease in the left supra-
clavicular fossa (Virchow’s node),
 palpable metastatic disease in the periumbilical area
(Sister Mary Joseph’s node)
 Pelvic metastatic disease palpable anteriorly on
rectal examination (Blumer’s shelf).

30. Biochemical investigations
LFT
Elevated bilirubin, alkaline phosphatase and GGT
Only mild to moderate elevations in liver
transaminases

31. CA 19-9
 Used in cases where diagnosis is in doubt.
 Elevated in 75% of patients with pancreas cancer.
 also elevated in benign conditions of the pancreas,
liver, and bile ducts.
 To measure response to therapy or for screening for
recurrence
 Fallacy – can not be used in cases of jaundice.

32. Imaging
 ultrasonography
 Computed tomography (CT),
 Endoscopic ultrasound (EUS)
 Magnetic resonance imaging (MRI) with or without
magnetic resonance cholangio-pancreatography (MRCP)
 Endoscopic retrograde cholangio-pancreatography
(ERCP)
 Positron emission Tomography (PET)

33. Ultrasonography
 Initial investigation
 The sensitivity is low, and the absence of a
pancreatic mass by ultrasonography does not rule
out ca pancreas, Also pick up hepatic metastases,
pancreatic massesp, eripancreatic and hilar
lymphadenopathy, and ascites.

34. CT Scan for pancreas
 Multi-detector spiral CT and is the single most useful
diagnostic and staging modality.
 It gives information about adjacent vascular
structures such as the portal, superior mesenteric,
and splenic veins, as well as the superior mesenteric
artery (SMA) and celiac axis.

35. Phases of an pancreatic protocol CT
scan
 Non Contrast CT
 Early arterial phase (15-20 s after injection of
contrast)
 Late arterial phase (35-40 s)
 Hepatic or portal venous phase (50-60s)
 Nephrogenic Phase (100 s)
 Delayed phase (6-10 minutes)

36.  The non contrast phase - pancreatic calcifications,
for localization of the precise levels the post contrast
study.
 The early arterial phase permits evaluation of
pancreatic vasculature without interference from
venous opacification.

37.  The late arterial phase - distinguish pancreatic
neoplasms from adjacent normal pancreatic tissue,
to evaluate hyper-vascular liver metastases
(neuroendocrine tumors of the pancreas).
 The 4th phase portal venous phase - for hypo-
vascular liver metastases

38. Unresectability in CT
 Unresectability is defined on multiphase CT by
involvement of
1. ≥ 180 degrees of the celiac axis
2. hepatic or superior mesenteric artery, enlarged lymph
nodes outside the boundaries of resection
3. ascites, and distant metastases.
 Invasion of the superior mesenteric vein or portal vein is
not in itself a contraindication to resection as long as the
veins are patent. Resection of vein with reconstruction is
possible.

39. CT images
Dilated intrahepatic ducts. Double-duct sign” with dilated common bile duct and
pancreatic ducts. There is a stent in the common bile duct
(S)

40. Pancreas cancer mass with stent through it (arrow).
Superior mesenteric artery (SMA) (A) is adjacent to
tumor.
Tree-dimensional CT vascular reconstruction
Portal and superior mesenteric veins
do not appear involved.

42. ENDOSCOPIC ULTRASOUND ( EUS
)
Sensitivity ranges from 69 to 94%.
Superior than CT for detecting the lesions smaller
than 2cm
It is superior to CT for the venous invasion but it is
less useful in determination of arterial involvement.

43.  Another advantage of EUS is the ability to obtain tissue for
biopsy via FNA.
 With EUS, the issue of needle-tract tumour seeding is
minimized, as the FNA is generally performed through a
segment of duodenal or stomach wall that will be removed as
part of a resection,

44. The duodenum, ampulla, head of the
pancreas, and uncinated process of the
pancreas are accessible with an
ultrasound probe positioned in the
duodenum.
The body and tail of the pancreas are
accessible with an ultrasound probe
positioned in the stomach.

45. Images eus
Endoscopic ultrasound (EUS) image with linear array echoendoscope demonstrating a mass in the
head of the pancreas with no vascular invasion of the superior mesenteric artery (SMA), superior
mesenteric vein (SMV), or portal vein (PORTAL).

46. MRI and MRCP
 MRI, MRA, and MRCP can be performed in a single
setting.
 has the potential to provide information about tumour
size and extent, biliary and pancreatic ductal
anatomy, and vascular involvement through a single,
non-invasive procedure.
 Motion artefact, lack of bowel opacification,
compromised resolution, and patient discomfort from
the longer scanning times are disadvantages.

47. MRI Vs CT
 There is no significant diagnostic advantage of MRI
over contrast- enhanced CT
 MRI is better at characterizing cystic lesions of the
pancreas
 has the capability to evaluate the bile ducts both
above and below a stricture, and can also identify
intrahepatic mass lesions

48. T1-weighted MR images with gadolinium contrast. A mass in the head
of the pancreas appears hypodense.

49. Single-shot spin-echo MR cholangiopancreatogram of patient with obstructive jaundice. Both the
common bile duct and the pancreatic duct are dilated. The hypointense tumor is apparent in the
periampullary region.

50. ERCP
 ERCP may be of benefit in patients with biliary
obstruction and cholangitis - endoscopic stent can be
placed for decompression.
 With current capabilities of CT and MRI, ERCP is
rarely necessary.

51. Endoscopic retrograde cholangiopancreatogram
(ERCP) of patient with pancreas cancer with abrupt
cut-off of main
pancreatic duct secondary to tumor.
ERCP of patient with pancreas cancer with
obstruction of both main pancreatic duct and common
bile duct

52. Indications for pre operative
decompression of biliary system.
 Cachexic patient for nutritional improvement.
 In patients with cholangitis
 If your plan is non operative management.

53. Tissue diagnosis
 A tissue diagnosis of adenocarcinoma is not
required prior to an attempt at a curative
resection.
 Fibrosis in pancreatic cancer- may miss the
malignant glands, so sensitivity is less.
 Does not change treatment decision in a
planned curative surgery.

54. FNA is required if
1. Patients undergoing neoadjuvant therapy.
2. If the diagnosis of carcinoma is uncertain.
3. In suspected neuroendocrine cancers, lymphomas,
cystic lesions, FNA result may alter the treatment.

55. Staging
 CT, EUS, MRI to detect local disease.
 Chest x-ray with SOS CT chest,
 Staging laparoscopy- varies between institutions.

56. AJCC Staging

57. Staging of Pancreatic Cancer
 TX: Primary tumor cannot be assessed
 T0: No evidence of primary tumor
 Tis: Carcinoma in situ
 T1: Limited to pancreas, ≤ 2 cm in greatest dimension
 T2: Limited to the pancreas, >2 cm in greatest dimension
 T3: Extends beyond the pancreas, without involving of the celiac
axis or the superior mesenteric artery
 T4: Involves the celiac axis or the superior mesenteric artery
(unresectable).

58.  Regional lymph nodes
- NX: Regional lymph nodes cannot be
assessed
- N0: No regional lymph node metastasis
- N1: Regional lymph node metastasis
present
 Distant metastasis
- MX: Distant metastasis cannot be
assessed
- M0: No distant metastasis
- M1: Distant metastasis

59. Stage grouping

60. Management

61. Surgical Procedures
 Head of the pancreas:
Whipple Procedure

62. Allen Oldfather Whipple
(1881-1963)
 Pancreatico-duodenectomy (PD)
was first performed by Kausch in
1908, and popularized by Whipple
in the 1930s (who performed 37
procedures).
—Whipple AO, Parsons WB,
Mullins CR.
Treatment of Carcinoma of the Ampulla of Vater.
Ann Surg 1935; 102: 763-769.

65. STEP 1 EXPOSURE OF INFRA PANCREATIC
SMV
 The lesser sac is entered,
The inferior body of the
pancreas is identified.
 The superior mesenteric
vein (SMV) is exposed at
the inferior border of the
neck of the pancreas
adjacent to the uncinate
process.

66. STEP 2 KOCHERS MANEUVERE
 A Kocher maneuver has been
performed by first identifying the
inferior vena cava (IVC) at the level
of the proximal portion of the
transverse segment of the
duodenum (D3).
 One can then mobilize the
duodenum and pancreatic head off
of the IVC in a cephalad direction
thereby removing all soft tissue
anterior to the IVC.
 Note that the Kocher maneuver is
continued to the left lateral border
of the aorta .

67. STEP 3: PORTAL DISSECTION
 Dissection of the porta hepatis begins
with identification of the common
hepatic artery (CHA), by removal of
the large lymph node which
commonly sits anterior to this vessel.
 The CHA is then followed distally to
allow identification and division of the
right gastric artery and the
gastroduodenal artery (GDA).
 This allows the CHA to be mobilized
off of the underlying anterior surface
of the portal vein (PV). The PV is
always identified prior to division of
the common hepatic duct (CHD).

68. STEP 4: TRANSECT STOMACH
 The antrum of the stomach is
resected with the main
specimen by dividing the
stomach at the level of the third
or fourth transverse vein on the
lesser curvature.
 Sometimes the entire stomach is
preserved; when this is done,
the operation is called a pylorus
preserving Whipple (or
pancreaticoduodenectomy).

69. STEP 5: TRANSECTION OF JEJUNUM
 Transection of the jejunum is
followed by ligation and division of
its mesentery. The loose
attachments of the ligament of Treitz
are taken down, and the fourth and
third portions of the duodenum are
mobilized by dividing their short
mesenteric vessels.
 The duodenum and jejunum are
then reflected underneath the
mesenteric vessels in preparation
for the final and most important part
of pancreaticoduodenectomy.

70. STEP 6: TRANSECT PANCREAS
 The pancreatic head and uncinate
process are separated from the
superior mesenteric-portal vein
confluence.
 The pancreas has been
transected at the level of the
portal vein and the pancreatic
head is reflected laterally, allowing
identification of small venous
tributaries from the portal vein and
superior mesenteric vein (SMV).
These tributaries are ligated and
divided.

73. Modified Whipple operation
—PPPD
 A more limited duodenectomy with preservation of
the stomach and antropyloric region is preferred by
some experts .

74. PPPD
Pylorus-preserving
pancreatico-
duodenectomy

75. Advantages of pyloric preservation
 Prevention of reflux of pancreaticobiliary secretions into
the stomach,
 decreased incidence of marginal ulceration,
 normal gastric acid secretion and hormone release, and
improved gastric function.
 Patients with pylorus-preserving resections have
appeared to regain weight better than historic controls.
 it is controversial whether there is any significant
improvement in long-term quality of life with pyloric
preservation.

76. Classic Whipple V.S. PPPD
 PPPD—protects against gastric dumping, marginal
ulceration, and bile reflux gastritis. Significant
reduction of the operation time, the intraoperative
blood loss and the consequent need for blood
substitution.
 But sufficiently radical to treat pancreatic cancer?
Similar or even better postoperative morbidity and
mortality result was debated.

77. Results following
Pancreaticoduodenectomy
Due to improved surgical skill and peri-operative care
 Mortality rate 20%-40% in earlier days
 During the past decades, dramatically decreased and
currently is between 0-4% in experience centers with
experience.
 Complication rate is still 30%-40%

78. Complications of
Pancreaticoduodenectomy
 Common
Delayed gastric emptying
Pancreatic fistula
Intra-abdominal abscess
Hemorrhage
Wound infection
Metabolic
Diabetes
Pancreatic exocrine
insufficiency
 Uncommon
Fistula (Biliary , Duodenal, Gastric )
Organ failure
Cardiac
Hepatic
Pulmonary
Renal
Pancreatitis
Marginal ulceration

79. CHEMOTHERAPY

80. Chemotherapy
 5 FU alone or combination with radiotherapy
 gemcitabine

81. ADJUVANT CHEMOTHERAPY
 Current recommendation for adjuvant chemotherapy
- gemcitabine
 capecitabine, a prodrug for 5-FU. It is sequentially
metabolized into active 5-FU by enzyme thymidine
phosphorylase-highly expressed in the tumour.

82.  This has four potential advantages:
1) systemic side effects are reduced,
2) high concentrations are achieved in the vicinity of
the tumor,
3) oral capecitabine has a pharmacokinetic profile
similar to that of a continuous systemic infusion 5-
FU, and
4) Patients tolerate it better than 5-FU.

83.  But clinical response in 24% and tumor response in
7% . Better responses when combined with
gemcitabine.

84. RADIOTHERAPY

85. INTRAOPERATIVE RADIOTHERAPY
 EBRT on the pancreatic bed is limited – adjascent
radiosensitive structures; so intraoperative
radiotherapy (IORT) is useful.
 Results unsatisfactory.

86. PALLIATIVE
CARE

87. Surgical Palliative procedures – Biliary
enteric bypass

88. Coeliac nerve block

89. Non operative palliation
 Nonoperative Palliation of Obstructive Jaundice
Per cutaneous drainage or endoscopic stenting
 Nonoperative Palliation of Duodenal Obstruction
Self expanding gastro duodenal stenting

90. PALLIATIVE CHEMOTHERAPY
 Gemcitabine is more beneficial than 5-FU when used
as monotherapy in advanced pancreatic cancer.
 Those receiving gemcitabine had a modest but
significant increase in median survival (5.56 vs. 4.41
months; P = .0025) and improved clinical benefit
(23.8% vs. 4.8%; P = .0022).

91. PALLIATIVE RADIOTHERAPY
 Hyper fractionation and IMRT – Better tolerance

92. Thank you...