Presentation by Dr. Aziz Ahmad, Surgical Oncology, Mills-Peninsula Medical Center, April 23, 2011.

1. Pancreatic Cancer Aziz Ahmad, MD Surgical Oncology Mills-Peninsula Hospital April 23, 2011

2. Statistics 10th most common cancer 4th leading cause of cancer death

3. Statistics 80% of cases are adenocarcinomas from exocrine pancreas Less common exocrine tumors include: IPMN Mucinouscystadenocarcimomas Islet cell tumors Insulin, glucagon, VIP, sandostatin, gastrin, nonsecreting Most common in black males Median age of diagnosis is 70

4. 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, Ataxia-Telangiectasia, Hereditary Pancreatitis, FAMMM-PC

5. Presentation Nonspecific symptoms Tumors of body and tail (25%) Pain and weight loss Tumors of the Head (75%) Jaundice, steatohrrea, weight loss, Couvoirsier’s sign, pain Labs Increased LFTs, elevated CA19-9

6. 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

7. 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

8. 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

9. 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)

10. 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

11. 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%

12. Surgical Procedures Tumors of the Body and Tail Laparoscopic distal pancreatectomy Removal of body & tail of pancreas spleen

13. Surgical Procedures Head of the pancreas: Whipple Procedure Removal of: Distal stomach Duodenum and proximal jejunem Head of pancreas Gallbladder and common bile duct

14. Complications Whipple Procedure bleeding Gastroparesis Pancreatic duct leak Bile duct leak Diabetes malabsorption Distal pancreatectomy Bleeding Pancreatic duct leak Malabsorption diabetes

15. 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

16. 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

17. 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

18. 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