Pancreatic Cancer

Aziz Ahmad, MD Surgical Oncology Mills-Peninsula Hospital April 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, AtaxiaTelangiectasia, 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, Couvoirsiers 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