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Pancreas Ca

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DanishMandi

This document discusses carcinoma of the head of the pancreas. It begins with a case presentation of a 55-year-old female patient presenting with jaundice for 1 year and itching for 1 day. Her history and examination are provided. Imaging including CT scan revealed a mass in the head of the pancreas. The document then discusses pancreatic carcinoma, including risk factors, location, clinical features, investigations, staging, and management. Surgical options like the Whipple procedure are outlined as well as chemotherapy and palliative treatments. Multiple choice questions related to pancreatic cancer are also provided.

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Pancreas Ca
CARCINOMA OF HEAD OF PANCREAS By DR. DANISH RAUF HOUSE OFFICER, CMH BAHAWALPUR Supervisor Col Malik Saeed Awan Assistant Professor and HOD Surgery Consultant General and Laparoscopic Surgeon CMH BWP
CMH BWP SEQUENCE Case Presentation Case Discussion
CASE PRESENTATION CMH BWP
HISTORY PATIENT PROFILE Name: XYZ Age: 55 years Gender: female Residence: Bahawalpur Date of presentation: 28 august , 2022 CMH BWP
PRESENTING COMPLAINTS Jaundice-01 year Itching- 01 day CMH BWP
HOPI JAUNDICE My patient was in usual state of health 1 year back when she noticed yellowing of her eyes. CMH BWP
PRURITIS Patient also had complain of Itching on whole body for last 2 months. It was increasing progressively. Relieved with medical ointment.
HOPI CONT Had poor appetite Loss of 1/3rd of body weight in last 2 months Pale stools : last 1 year Dark yellow urine There were no complaints of fever diarrhea or constipation
PAST HISTORY Medical hx: DM Positive(7 Years) Personal History: Poor Appetite Poor Bowel Habits Drug History: Oral medications for diabetes No hx of any drug or food allergies Positive Family History CMH BWP
SYSTEMIC EXAMINATION GPE: Well oriented in time place and person Jaundice positive Vitals: BP: 130/90 mmHg Pulse: 92 bpm SPO2: 97% Temp: 98 degree F
SYSTEMIC EXAMINATION Respiratory: CVS: CNS: Musculoskeletal CMH BWP UNREMARKABLE
SYSTEMIC EXAMINATION Abdominal Examination: Inspection: unremarkable Palpation: GB palpable 2 fingers below the right coastal margin No visceromegaly Auscultation: BS normal
INVESTIGATIONS All baselines Blood CP: TLC:11.9 Hb : 9.1 Plt : 385 Clotting Profile: PT : 26 APTT: 48 Urine R/E: Colour : deep yellow CMH BWP
INVESTIGATIONS LFTS: S.Total bilirubin : 245 (less than 17) S. ALT : 103 (UPTO 36) S. ALP : 1334 (LESS THAM 120) S. AMYLASE : 183 HEP B and C Negative CMH BWP
RADIOLOGICAL FINDINGS X-Ray: Normal study
Ultrasound
CT SCAN
CARCINOMA HEAD OF PANCREAS
Objectives: anatomy Epidemiology Clinical features Management
PANCREA S
Pancreas Ca
Pancreas Ca
Pancreas Ca
NORMAL (50%)
CARCINOMA HEAD OF PANCREAS Incidence is about 8 to 9 cases per 1,00,000 population. 74% of patients die within the first year after diagnosis, with 5-year survival rate of only 6%.
RISK FACTORS Environmental Genetic
RISK FACTORS DEFINITIVE ASSOCIATION Smoking 1 3 times risk, Directly proportional to the quantity and duration of smoking (i.e. pack year).
Obesity
DIET
GENETIC RISK FACTORS
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.
CLINICAL FEATURES
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.
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
CLINICAL SIGNS
SIGNS OF ADVANCED DISEASE Cachexia palpable nodules in the liver palpable metastatic disease in the left supra- clavicular fossa (Virchows node), palpable metastatic disease in the periumbilical area (Sister Mary Josephs node) Pelvic metastatic disease palpable anteriorly on rectal examination (Blumers shelf).
VIRCHOWS NODE
SISTER MARY JOSEPH NODES Sister Mary Josephs node)
SISTER MARY JOSEPH
DR WILLIAM JAMES MAYO
BLUMMER SHELF
BIOCHEMICAL INVESTIGATIONS LFT Elevated bilirubin, alkaline phosphatase and GGT Only mild to moderate elevations in liver transaminases
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.
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)
ULTRASONOGRAPHY
Dilated intrahepatic ducts. Double-duct sign with dilated common bile duct and pancreatic ducts. CT SCAN
EUS
MRI images with gadolinium contrast.
MRCP of patient with obstructive jaundice.
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.
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
TISSUE DIAGNOSIS A tissue diagnosis of adenocarcinoma is not required prior to an attempt at a curative resection. Does not change treatment decision in a planned curative surgery.
FNA IS REQUIRED IF 1. Patients undergoing neoadjuvant therapy. 2. If the diagnosis of carcinoma is uncertain.
STAGING CT, EUS, MRI to detect local disease. Chest x-ray with SOS CT chest, Staging laparoscopy- varies between institutions.
AJCC STAGING
STAGE GROUPING
MANAGEMENT
Surgical Procedures WHIPPLE PROCEDURE
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.
Pancreas Ca
Pancreas Ca
Pancreas Ca
CHEMOTHERAPY 5 FU alone or combination with radiotherapy gemcitabine
PALLIATIVE TREATMENT Relief of Jaundice
Relief Of Duodenal Obstruction
Relief of pain 1 ) Morphine 2 ) Chemical Ablation of Celiac Ganglia
MCQS The risk factors for pancreatic cancer includes all except: A. Diabetes mellitus B. Hereditary predisposition C. Chronic pancreatitis D. Smoking E . Acute pancreatitis
ANSWER E
The differential diagnosis of a mass lesion in pancreas includes all except: The differential diagnosis of a mass lesion in pancreas includes all except: 1. Lymphoma 2. Neuroendocrine tumour 3. Focal chronic pancreatitis 4. Autoimmune pancreatitis 5. None of the above
ANSWER E
A 65 year old gentleman presented with dull aching upper abdominal pain radiating through to the back and worsened by eating. He had also noticed yellow discoloration of his skin and had lost weight. In his past medical history, he was diagnosed with diabetes mellitus 6 months earlier. A CT scan revealed a localised mass lesion in the head of pancreas with biliary duct dilatation. All the following are true except: A. CT guided biopsy is needed to confirm the diagnosis B. A diagnosis of pancreatic cancer should be considered in unexplained diabetes (no family history, obesity or steroids) in patients over 50 years of age. C. Gastroduodenal artery encasement is not a contraindication for curative surgery D. Whipples operation is the standard operation for cancer of pancreatic head
ANSWER A
Pancreas Ca
Pancreas Ca
Pancreas Ca
Pancreas Ca

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Pancreas Ca

  • 2. CARCINOMA OF HEAD OF PANCREAS By DR. DANISH RAUF HOUSE OFFICER, CMH BAHAWALPUR Supervisor Col Malik Saeed Awan Assistant Professor and HOD Surgery Consultant General and Laparoscopic Surgeon CMH BWP
  • 5. HISTORY PATIENT PROFILE Name: XYZ Age: 55 years Gender: female Residence: Bahawalpur Date of presentation: 28 august , 2022 CMH BWP
  • 6. PRESENTING COMPLAINTS Jaundice-01 year Itching- 01 day CMH BWP
  • 7. HOPI JAUNDICE My patient was in usual state of health 1 year back when she noticed yellowing of her eyes. CMH BWP
  • 8. PRURITIS Patient also had complain of Itching on whole body for last 2 months. It was increasing progressively. Relieved with medical ointment.
  • 9. HOPI CONT Had poor appetite Loss of 1/3rd of body weight in last 2 months Pale stools : last 1 year Dark yellow urine There were no complaints of fever diarrhea or constipation
  • 10. PAST HISTORY Medical hx: DM Positive(7 Years) Personal History: Poor Appetite Poor Bowel Habits Drug History: Oral medications for diabetes No hx of any drug or food allergies Positive Family History CMH BWP
  • 11. SYSTEMIC EXAMINATION GPE: Well oriented in time place and person Jaundice positive Vitals: BP: 130/90 mmHg Pulse: 92 bpm SPO2: 97% Temp: 98 degree F
  • 12. SYSTEMIC EXAMINATION Respiratory: CVS: CNS: Musculoskeletal CMH BWP UNREMARKABLE
  • 13. SYSTEMIC EXAMINATION Abdominal Examination: Inspection: unremarkable Palpation: GB palpable 2 fingers below the right coastal margin No visceromegaly Auscultation: BS normal
  • 14. INVESTIGATIONS All baselines Blood CP: TLC:11.9 Hb : 9.1 Plt : 385 Clotting Profile: PT : 26 APTT: 48 Urine R/E: Colour : deep yellow CMH BWP
  • 15. INVESTIGATIONS LFTS: S.Total bilirubin : 245 (less than 17) S. ALT : 103 (UPTO 36) S. ALP : 1334 (LESS THAM 120) S. AMYLASE : 183 HEP B and C Negative CMH BWP
  • 20. Objectives: anatomy Epidemiology Clinical features Management
  • 26. CARCINOMA HEAD OF PANCREAS Incidence is about 8 to 9 cases per 1,00,000 population. 74% of patients die within the first year after diagnosis, with 5-year survival rate of only 6%.
  • 28. RISK FACTORS DEFINITIVE ASSOCIATION Smoking 1 3 times risk, Directly proportional to the quantity and duration of smoking (i.e. pack year).
  • 30. DIET
  • 32. 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.
  • 34. 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.
  • 35. 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
  • 37. SIGNS OF ADVANCED DISEASE Cachexia palpable nodules in the liver palpable metastatic disease in the left supra- clavicular fossa (Virchows node), palpable metastatic disease in the periumbilical area (Sister Mary Josephs node) Pelvic metastatic disease palpable anteriorly on rectal examination (Blumers shelf).
  • 39. SISTER MARY JOSEPH NODES Sister Mary Josephs node)
  • 43. BIOCHEMICAL INVESTIGATIONS LFT Elevated bilirubin, alkaline phosphatase and GGT Only mild to moderate elevations in liver transaminases
  • 44. 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.
  • 45. 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)
  • 47. Dilated intrahepatic ducts. Double-duct sign with dilated common bile duct and pancreatic ducts. CT SCAN
  • 48. EUS
  • 50. MRCP of patient with obstructive jaundice.
  • 51. 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.
  • 52. 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
  • 53. TISSUE DIAGNOSIS A tissue diagnosis of adenocarcinoma is not required prior to an attempt at a curative resection. 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.
  • 55. STAGING CT, EUS, MRI to detect local disease. Chest x-ray with SOS CT chest, Staging laparoscopy- varies between institutions.
  • 60. 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.
  • 64. CHEMOTHERAPY 5 FU alone or combination with radiotherapy gemcitabine
  • 66. Relief Of Duodenal Obstruction
  • 67. Relief of pain 1 ) Morphine 2 ) Chemical Ablation of Celiac Ganglia
  • 68. MCQS The risk factors for pancreatic cancer includes all except: A. Diabetes mellitus B. Hereditary predisposition C. Chronic pancreatitis D. Smoking E . Acute pancreatitis
  • 70. The differential diagnosis of a mass lesion in pancreas includes all except: The differential diagnosis of a mass lesion in pancreas includes all except: 1. Lymphoma 2. Neuroendocrine tumour 3. Focal chronic pancreatitis 4. Autoimmune pancreatitis 5. None of the above
  • 72. A 65 year old gentleman presented with dull aching upper abdominal pain radiating through to the back and worsened by eating. He had also noticed yellow discoloration of his skin and had lost weight. In his past medical history, he was diagnosed with diabetes mellitus 6 months earlier. A CT scan revealed a localised mass lesion in the head of pancreas with biliary duct dilatation. All the following are true except: A. CT guided biopsy is needed to confirm the diagnosis B. A diagnosis of pancreatic cancer should be considered in unexplained diabetes (no family history, obesity or steroids) in patients over 50 years of age. C. Gastroduodenal artery encasement is not a contraindication for curative surgery D. Whipples operation is the standard operation for cancer of pancreatic head