Disease Review

Malignant pancreatic tumor

Epidemiology
The fourth leading cause of cancer death in US
3%
M>F
60-80yrs ( rare in under 40 )
Risk factors : family history of pancreatic cancer, hereditary o
r chronic pancreatitis, cigarette smoking, occupational expos
ure to carcinogen
Relationship with DM : controversial

Anatomy
Pancreas division
1) Major papilla : Duct of Wirsung(ventral pancreas)
2) Minor papilla : Duct of Santorini(sup head, neck, body,t
ail)
Blood supply
1) Gastroduodenal artery<==Celiac trunk
2) Pancreatoduodenal artery(ant & post)<==SMA
3) splenic artery <==Celiac trunk

Pathology
Ductal adenocarcinoma : 90 %
Head and uncinate process : 70 % among ductal adenocarci
noma
Hard, irregular, gritty mass, poorly demarcated, halo surroun
ds tumor d/t obstruction of duct
Perineural growth ; upper abdominal and back pain
Body or tail tumor ; larger and detected lately

Genetic consideration
codon 12 mutations of the K-ras oncogene (grwoth promo
ting oncogene)
inactivation of tumor suppressor genes ; p16, p53, SMAD4
excessive expression of growth factor receptor ; EGF-R
Up to 16% of pancreatic cancers are thought to be inherited

Symptoms and Signs

Insidious tumor
By the location of tumor
Head or uncinate process > duct obstruction Sx
Pancreatitis, painless jaundice (obstructive), N/V, steatorrhe
a, unexplained weight loss

Diagnosis
Contrast- enhanced spiral CT : Choice
hypodense mass with poorly demarcated edge, have a more hypodense center indi
cating central necrosis or cystic change

MRCP for accurately depicting the level and degree of bile /

pancreatic duct dilatation
ERCP, EUS, FDG-PET
Serum marker : CEA, CA 19-9
PreOP percutaneous biopsy : controversial

Staging of Pancreatic cancer

Staging of Pancreatic cancer

Stage I and II cancers are amenable for resection.

Stage III and IV cancers are considered to be unresectable

- Due to major arterial involvement (III)
- Due to distant metastasis (IV)

Resectional Surgery for Pancreatic Head and Uncinate proce

ss tumors
Pancreaticoduodenectomy without preservation of the pylor

us and proximal duodenum (classic Whipple surgery)

Figures from Freelove et al.

Resectional Surgery for Pancreatic Head and Uncinate proce

ss tumors
Pancreaticoduodenectomy with preservation of the pylorus a
nd proximal duodenum
-Pylorus preserving Pancreaticoduodenectomy: PPPD

Figures from Johns Hopkins Medicine

Common Complications of Pancreaticoduodenectomy

Operative mortality rate is 2% ~ 4%

Anastomotic leaks
-occurs in 15% to 20% of patients, from pancreatic anastomosis(pancre
atic fistula)

Intra-abdominal abscesses

Delayed gastric emptying

-occurs in 15% to 40% of patients, resolves with time

Prognosis of Pancreatic cancer

Pancreaticoduodenectomy for Stage I, II
-Five year survival rate 10% to 15%
-most of those patients who survive for 5 years succumb over t
he subsequent 5 years.
-presence or absence of tumor at the resection margin is the m
ost critical factor

Stage III
-Mean survival ranges from 8 to 12 months

Stage IV
-Mean survival ranges from 3 to 6 months

Reference
Sabistons Textbook of Surgery, 18th edition, 1589-1619
Harrisons Principles of Internal Medicine, 18th edition, 786-789 Freelove R, Walling AD Pancreatic cancer: diagnosis and management.
Am Fam Physician. 2006;73(3):48592 PubMed 16477897.
Johns Hopkins Medicine, The Whipple Procedure, (http://pathology.j
hu.edu/pc/whipplePop.php)

End of Document