Pancreatic TumorsMargo Shoup, MDAssociate Professor of SurgeryLoyola University Medical Center

Pancreatic TumorsIntroduction 38,000 cases a year Risk factors– Smoking– Pancreatitis Real risk, but only 5% ofpancreatic cancer patients

Pancreatic TumorsGenetics Tumor suppressor gene p53Mitogen activating gene k-rasCOX-2VEGF

Pancreatic TumorsDefinitions Most common malignant pancreatic tumoris pancreatic ductal adenocarcinoma Difficult at diagnosis to determine etiology– Periampullary tumor Pancreatic –65%Distal bile ductAmpullaDuodenumIslet cell

Pancreatic TumorsClassification of pancreatictumors Cystic tumors– Cystadenoma SerousMucinousIntraductal papillary mucinousSolid and Pseudopapillary

Pancreatic TumorsSurgical Options Enucleation Distal pancreatectomy with or withoutsplenectomy Central pancreatectomy Ampullectomy Pancreaticoduodenectomy

Pancreatic TumorsClassification of pancreatictumors Malignant– Adenocarcinoma distal bile duct– Cystadenocarcinoma Mucinous Intraductal papillary– Acinar Endocrine

Pancreatic TumorsTumor Markers CA 19-9– Most commonly valued marker– Not specific, high levels seen in benign disease– Normalization following resection appears to beassociated with improved outcome– Rising level after resection is a marker of relapse– Levels 1500 correlate with unresectable tumors Not cost effective for screening

Pancreatic TumorsClinical suspicion Patients with pancreatic cancer commonly presentwith advanced disease– Head tumors – proximity to vascular structures– Body and Tail – metastatic disease Symptoms are nonspecific– Vague discomfort, dyspepsia, bloating– Jaundice– Weight loss, back pain usually a sign of advancedisease– Significant back pain 9% resectability vs minimal backpain 31% resectability– New onset diabetes in patients over 60 should raisesuspicion.

Pancreatic TumorsDiagnosis History––––Weight lossChange in urine and stoolGastric outlet symptomsBack pain Physical– Jaundice– Cachectic– Palpable mass

Pancreatic TumorsWork up CBCLiver function testsHepatitis profileHemolytic profileUltrasoundCT – identify mass, evaluate vesselinvolvement ERCP – double duct sign for head mass EUS – If not sure if pancreatitis vs tumor

Pancreatic TumorsCT Findings Adenocarcinoma––––Irregular borderNot hypervascularPancreatic ductal dilatationDistal pancreatic atrophy

Pancreatic adenocarcinoma

Pancreatic adenocarcinoma

Pancreatic TumorsCT Findings Neuroendocrine– Well circumscribed– Hypervascular– No atrophy Cystic– Appear fluid filled– Well circumscribed

Neuroendocrine Tumor

Intraductal papillary mucinous neoplasm

Pancreatic TumorsERCP Not usually necessary Often performed if seen byGastroenterologists Necessary if biliary stent is needed Double duct sign– Strictured common bile duct and pancreaticduct Biopsy possible, not always needed

Pancreatic TumorsTreatment Options Tissue diagnosis – NOT NECESSARY– Unless surgery is not planned Potentially resectable tumors– Laparoscopy to rule out metastatic disease– Head tumors – pancreaticoduodenectomy Pancreatic head, distal common bile duct, duodenum, /antrum, gallbladder Pancreaticogastrostomy or jejunostomy, hepaticojejunostomy,gastrojejunostomy– Body or Tail tumors – distal pancreatectomy withsplenectomy

Reconstruction Following StandardPancreaticoduodenectomy

Reconstruction Following PylorusPreserving Pancreaticoduodenectomy

Pancreatic TumorsPrognosis after surgery 1-3% perioperative mortality rate in the besthands (30-day or same admisstion mortality)– Previously was 20% 5 year survival–––––Pancreas – 10-15%Bile Duct – 15-20%Duodenum – 50%Ampulla – 35%Islet cell – 40%

Adjuvant therapy Options for chemotherapy and radiotherapy– Inconclusive evidence that CRT improvessurvival– GITSG trial– 43 patients randomized to CRT vs. no CRT– CRT had improved survival Neoadjuvant therapy– Clinical trials

Pancreatic TumorsPredictors of outcome Nodal status Size ( 2cm) Margin status

Pancreatic TumorsComplications Pancreatic duct leak/fistula– Drain amylase level more than 3x serum– 10-20% Biliary leak/Gastrojejunostomy leak– Less common Delayed gastric emptyingPancreatitisDiabetesDumping syndrome – exocrine insufficiency

Pancreatic TumorsFollow-up If patients are asymptomatic follow with physicalexam and history If patients start to become symptomatic, obtain CT– Weight loss– Anorexia– Weakness Someone will order a CT sooner– Patients peace of mind What to do with results if a recurrence is noted?– Treatment with chemotherapy in the metastatic settinghas not been shown to prolong life.

Pancreatic TumorsUnresectable Majority of patients Locally advanced, not metastatic – May receivechemotherapy with radiation.– A small number of patients will respond enough tobecome resectable.– Median Survival 4-5 months if metastatic– Median Survival 7-9 months if not metastatic Back pain can be palliated with celiac axisblockade – alcohol injection

Pancreatic TumorsUnresectable Metastatic disease – treatment options limited toexperimental medications and chemotherapy. Patients should have biliary stent placed by ERC(Endoscopic retrograde cholangiogram)– If unable to place stent due to technical difficulties,should have operative biliary bypass– Choledochojejunostomy, Hepaticojejunostomy,Cholecystojejunostomy If considering CRT – need biopsy

Pancreatic TumorsUnresectable Disease Biliary stents– Plastic stent Best if patient considered for surgery 3- month longevity Easily removed– Metal “Wallstent” Permanent Lasts 6 months to a year Difficult to remove surgically

Laparoscopic StagingDefining Non-resectability Histologically confirmed hepatic, serosal,peritoneal or omental metastasis Celiac or high portal node involvement Tumor extension outside of pancreas Extensive portal vein involvement by tumor orinvasion/encasement of celiac axis, hepaticartery, or superior mesenteric artery.

Laparoscopic StagingLaparoscopically DetectedLiver Metastasis

Laparoscopic StagingLocally Advanced Tumors Considered candidates for chemoradiation ifmetastatic disease is not present. May be considered for subsequent surgicalresection depending on the response to thechemoradiation. Patients with pancreatic adenocarcinomametastatic to the liver or peritoneum arecandidates for palliative chemotherapy, butnot radiation.

Laparoscopic StagingLocally Advanced Pancreatic Cancer Contemporary imaging modalities failed todetect metastatic disease in 37% of patients. Patients considered for protocols includingradiation for locally advanced pancreaticcancer should be staged laparoscopicallyprior to initiating therapy.

Pancreatic TumorsEnd of Life Issues Pancreatic cancer– Almost as many people die each year from the diseaseas are diagnosed each year– Pain/Back pain Biggest issue Control with celiac block, fentanyl patch Palliative radiation– Gastric outlet obstruction – can be palliated byduodenal stent or gastric bypass (gastrojejunostomy) Patients with advanced disease should be referredto a hospice situation early

Pancreatic TumorsEnd of Life Options for treatment vs no treatment– Chemotherapy disappointing 5-FU, Gemcitabine, oxaliplatin– Quality of Life Radiation– Time consuming– 5 days a week for 6 weeks– Benefit not guaranteed

Pancreatic TumorsEnd of Life Questions from patients –––––How much time do I have?Will you still be my doctor?How will I die?What should I do now?

Case 1 52 year old man noted to have icteric scleraand mild jaundice, no pain. H&P PE Labs Differential Diagnosis

Case 1 Ultrasound– Dilated intra- and extra-hepatic bile ducts, nostones. Liver normal– CT – 3 cm mass in head of pancreas. No liverlesions. Dilated CBD and pancreatic duct(Double duct sign)– Now what?

Case 2 44 year old womanCT – pancreatic head massMultiple liver lesionsNow what?

Case 3 65 year old male had a screening CT scan atthe mall showing a 2 cm mass in the tail ofthe pancreas. Asymptomatic Differential Work up Treatment

Laparoscopic StagingRecommendations forPancreatic Cancer Laparoscopic––––Patients with resectable diseaseNo evidence of gastric outlet obstructionHave biliary stent, or can receive biliary stent if neededPatients with locally advanced tumors, no metastasis onimaging, considered for local therapy Open Exploration– Failed biliary stent– Gastric outlet obstruction