Pancreatic cancer develops from DNA damage to cells in the pancreas that causes uncontrolled growth. Most cases are ductal adenocarcinoma. Risk factors include smoking, obesity, family history, and chronic pancreatitis. Symptoms include jaundice, abdominal pain, weight loss, and fatigue. Diagnosis involves imaging like CT, MRI, and endoscopic ultrasound. Only 20% of cases are surgically resectable; the remainder receive chemotherapy, radiation, or supportive care. Prognosis is generally poor with a median survival of 4-6 months for metastatic disease.

1. Pancreatic Cancer
by
RAMKUMAR

2. Pancreas - Anatomy

3. Overview
• Pancreatic cancer develops when a cell in
the pancreas acquires damage to its DNA that causes
A single cell to grows and divides rapidly, becoming a
tumor that does not respect normal boundaries in
the body.

4. Pancreatic Epithelial Malignancies :
• Malignant
– Ductal adenocarcinoma (majority)
– Mucinous cystadenocarcinoma
– Acinar cell carcinoma
– Small cell carcinoma
• Uncertain malignant potential
– Mucinous cystadenoma
– Solid and cystic papillary neoplams

5. • Pathology:
– mostly ductal adenocarcinoma
(metastasizes early; presents late)
Location of tumor:
- 60% head
- 25% body
- 15% tail

6. Epidemiology:
• 10th most common cancer .
• 4th leading cause of cancer death.
• 80% of cases are adenocarcinomas from exocrine
pancreas
– Less common exocrine tumors include:
• IPMN
• Mucinouscystadenocarcimomas
• Most common in black males
• Median age of diagnosis is 70

7. Causes And Risk Factors:
• Pancreatic cancer is fundamentally a disease caused by
damage to the DNA. This damage is often referred to as
mutations.(Inheritance or Carcinogens).
• Smoking
• Age, gender
• Obesity
• Diet – high fat, low fibre
• Chronic pancreatitis
• Family history – BRCA2
• Β-napthylamine

8. Sign & Symptoms :
 Jaundice
 Pain in the upper or middle abdomen and back
 Unexplaind weight loss
 Loss of appetite
 Fatigue
 Trousseau’s syndrome
 Clinical Depression

9. Diagnostic Procedures:
• Identifying risk factors.
• Mass during physical Examination
• Ultrasound
– Bile duct distension
– Mass
• CT scan with IV contrast
– Triple phase CT (pancreas protocol) 90% accurate at finding
lesions
– A scanner takes multiple X-ray pictures, and a computer
reconstructs them into detailed images of the inside of the
abdomen

10. • Endoscopic ultrasound
– Help find lesions not seen on CT
– Help determine resectability
– Excellent way to get biopsy
• MR cholangiopancreatography (MRCP), which can be
used to look at the pancreatic and bile ducts, is described
below in the section on cholangiopancreatography.
• MR angiography (MRA), which looks at blood vessels, is
mentioned below in the section on angiography.

11. MRCP
ULTRASOUND CT SCAN

12. Endoscopic retrograde
cholangiopancreatography (ERCP):
• For this test, an endoscope (a thin, flexible tube with a tiny video
camera on the end) is passed down the throat, through the
esophagus and stomach, and into the first part of the small
intestine. This is usually done while you are sedated (given
medicine to make you sleepy).
• A small amount of dye (contrast material) is then injected into the
common bile duct, and x-rays are taken.
• The x-ray images can show narrowing or blockage in these ducts
that might be due to pancreatic cancer.
• ERCP can also be used to place a stent (small tube) into a bile or
pancreatic duct to keep it open if a nearby tumor is pressing on it.

13. • Stages of pancreatic cancer:
I II III IV

14. Stages :

15. Sites of Metastasis:
• Liver
• Peritoneum
• Lung
• Adrenal
• Bone
• Rarely CNS

16. Treatment Approach
Resectable disease
Stages I-II
(20%)
Surgery
Adjuvant chemotherapy
Adjuvant radiation

17. Treatment Approach
Inoperable disease
Locally Advanced stage
III
(30-40^)
Chemoradiation
Chemotherapy
Metatatic Stage IV
(40-50%)
Chemotherapy
Supportive Care

18. • Surgery:
Surgery with the intention of a cure is only
possible in around one-fifth (20%) of new cases.
• Whipple`s procedure
• total pancreatectomy
• distal pancreatectomy
– radiation therapy
– chemotherapy

19. • Whipple`s procedure:

20. Management of Locally Advanced Pancreatic
Cancer:
• Conventional external beam radiation therapy
• Concomitant Chemoradiotherapy
–5-FU
–Gemcitabine
–Paclitaxel

21. Management of Metastatic Pancreatic Cancer:
• Pain Control
– Long-acting narcotics
– Neurolytic celiac plexus block (NCPB)
• PERT
– PPI
– Bacterial overgrowth
• Endoscopic Stenting of Biliary and Pancreatic
Obstruction

22. Chemotherapy for Metastatic Pancreatic Cancer
• 5-FU
• Gemcitabine
– Median survival times versus 5-FU
– Survival rate at 12-months
– Toxicities
– Optimizing efficiency
Combination Chemotherapy Trials

23. Prognosis:
• 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%

24. Conclusions
 Since 1996, 20 randomized phase III trials have
failed to produce improvement in survival
outcomes.
 Metastatic pancreatic cancer is one of the most
frustrating malignancies to treat.
 For now, gemcitabine, gemcitabine + erlotinib, and
second-line treatment with OFF has shown benefit.
 Supportive care strategies should be emphasized.

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