Pancreatic Cancer

dr.Avit Suchitra,SpB-(K)BD
 Pancreatic Cancer Stats

http://www.cancerresearchuk.org/cancer-
info/cancerstats
 Incidence 2009-2011

http://www.cancerresearchuk.org/cancer-
info/cancerstats
 Risk Factors
Baseline ~ 10/100,000 population/year
Risk Proportion of cancers
Smoking x2 30
Genetic factors x 5-10 10
Chronic Pancreatitis x 10-20 1
Hereditary Pancreatitis x 35-70 <1
Age >70 x5 -
Type II DM x 1.5-2 -
Obesity x 1.7 -
High fat diet x 1.7 -
Previous gastric surgery x 1.8 -
Sclerosing Cholangitis x 14 -
Helicobacter Pylori x 1.8 -
Hereditary cancer syndromes
Peutz-Jeghers
FAMM
Familial breast/ovarian cancer
FPC
Hereditary Pancreatitis
Von Hippel-Lindau
Cystic Fibrosis
FAP
HNPCC
Pancreatic cancer: epidemiology
•Incidence of 10 per 100,000
•80% ductal adenocarcinoma
•10% other exocrine tissue–
Acinar cell,
cyst adenocarcinoma,
intraductal papillary mucinous
neoplasm (IPMN)
•10% neuroendocrine

KKrejs GJ. Dig Dis. 2010; 28:355-358

6
 ‘Classic’ symptoms
Obstructive Jaundice
50%
Truly ‘painless’ in about 10%, most will have some
pain, but not biliary colic
Pain
70%
Back / epigastrium
Relieved by sitting forward
Nausea / Vomiting
Weight Loss
Anorexia
 Other symptoms
New onset type 2 diabetes mellitus
underweight or normal weight patient, not associated with
weight gain
Resistant dyspepsia/persistent epigastric pain
IBS like symptoms in those >45 years
very rare as a new onset symptom at this age
Altered bowel habit
Increased bowel movement frequency and offensive smelling
stools
Suggestive of exocrine insufficiency
Venous Thromboembolism
may be a manifestation of an underlying abdominal malignancy
 Blood tests
Full blood count
anaemia rare except for ampullary tumours
Liver function tests
Obstructive jaundice
Elevated gamma GT / Alk Phos may precede bilirubin
Serum glucose
Diabetes or impaired glucose tolerance
CA19-9
Sensitivity of ~80% and a specificity of 83%
Normal levels do not exclude diagnosis
Better for treatment monitoring
Diagnostic tools for pancreatic cancer

Lab studies
– Tumor markers i.e.CA19-9
– Glucose intolerance
•Imaging modalities
– CT scan
– EUS
– ERCP
– MRI/MRCP
– PET scanning
– Staging laparoscopy
 Major clinical stages
Resectable -- Locally advanced -- Metastatic
TNM Staging
Stage 1
T1 (≤ 2cm) N0 M0
T2 (≥ 2cm) N0 M0
Stage 2
T3 (beyond the pancreas but with out involvement of celiac
axis or SMA) N0 M0
T1/2 N1 (regional LN) M0
Stage 3
T4 (involves celiac axis or SMA) Nx M0
Stage 4
M1
Metastasis, M0 vs M1
T1 (<2cm) vs T2 (>2cm)
T3 (Tumor extends beyond the pancreas but without involvement of the
celiac axis or the superior mesenteric artery) vs T4 (Tumor involves the
celiac axis or superior mesenteric artery (unresectable primary tumor))
N0 (No regional lymph node metastasis) vs
N1 (Regional lymph node metastasis)
 Anatomy and Surgical Resectability of Pancreatic Cancer.

Ryan DP et al. N Engl J Med 2014;371:1039-1049

 Stage 1 and 2
Radical pancreatic resection:
Whipple procedure (pancreaticoduodenal resection)
Total pancreatectomy when necessary for adequate
margins
Distal pancreatectomy for tumors of the body and tail of
the pancreas
Radical pancreatic resection with:
Postoperative chemotherapy (gemcitabine or 5FU)
Postoperative chemotherapy and radiation therapy
Whipple procedure
 Stage III
Technically unresectable because of local vessel
impingement or invasion by tumor
Benefit from palliation of biliary obstruction by
endoscopic, surgical, or radiological
Stage III and stage IV pancreatic cancer are both
incurable, the natural history of stage III (locally
advanced) disease may be different than it is for
stage IV disease
30% of patients presenting with stage III disease
died without evidence of distant metastases
 Treatments
Palliative surgical biliary and/or gastric bypass,
percutaneous radiologic biliary stent placement, or
endoscopic biliary stent placement
Chemotherapy with gemcitabine, gemcitabine and
erlotinib or abraxane, or FOLFIRINOX
Chemoradiation (for obstructions) followed by
chemotherapy
Chemotherapy followed by chemoradiation for
patients without metastatic disease --- now LAP07
trial worse with XRT
 Key Clinical Trials in Metastatic Pancreatic Cancer.

Ryan DP et al. N Engl J Med 2014;371:1039-1049

 Chemotherapy
>80% now receive adjuvant chemotherapy after
surgery (Gemcitabine +/- others)
Minority of unresectable patients fit for palliative
chemotherapy (Folfirinox)
50% if locally advanced
36% if metastatic
Role of neo-adjuvant chemotherapy currently
being explored
ESPAC-5
THANK YOU