Pancreatic Cancer

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Pancreatic Cancer

• Elizabeth Dehmer
• AM Report
• 5/2/08

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In the news.
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Epidemiology

• Increasing incidence over the past few decades in
  the US
• 4th leading cause of cancer death in US
• Estimated new cases and deaths in 2008
• Cases 37,680
• Deaths 34,290

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Risk Factors

• Smoking
• Advanced age
• Male sex (MF 1.31)
• Chronic pancreatitis
• Diabetes mellitus
• ?Obesity (BMIgt30 compared w/ lt23)
• total physical activity was inversely associated
  with risk among individuals with a BMI of at
  least 25 kg/m2
• ?Height

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Risk Factors

• Family History 5-10 of pts with pancreatic ca
  have a first degree relative with the disease
• Several case control and cohort studies of
  kindreds with familial aggregations ? odds ratio
  of developing pancreatic cancer ranges from
  1.5-5.25
• Patients in these families present at an earlier
  age. Smoking contributes to risk.

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Risk Factors

• Familial Syndromes associated w/ increased risk
• familial atypical multiple-mole melanoma
• familial breast cancer (BRCA-2)
• Peutz-Jeghers
• hereditary nonpolyposis colorectal cancer
• hereditary chronic pancreatitis

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Clinical Presentation

• Jaundice (50 of patients)
• Weight loss
• Anorexia
• Bloating
• Steatorrhea or diarrhea
• Abdominal pain or back pain or both

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Diagnosis

• Abdominal Ultrasound
• CT Abdomen
• Biopsy (Percutaneous or Endoscopic)
• Serum CA 19-9
• Elevated in 80 of pancreatic ca cases
• Low specificity
• Can be a useful gauge of treatment

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Staging
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Treatment

• Localized Radical pancreatic resection /-
  post-op radiation and/or chemotherapy
• (5-FU or gemcitabine)
• Locally Advanced chemotherapy /-radiation or
  clinical trial
• Metastatic Disease
• chemotherapy (gemcitabine)

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Treatment

• At the time of diagnosis
• 15-20 of pts have localized and resectable
  tumors
• 40-45 have localized tumors that are
  unresectable (generally due to vascular invasion)
• 40-45 have distant metastases
• Contraindications to surgical resection
• Mets to liver, peritoneum, omentum, or any
  extra-abdominal site
• Encasement of celiac axis, hepatic artery or SMA
• Involvement of splenoportal confluence
• Involvement of bowel mesentary
• Involvement of SMV or portal vein

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Treatment

• Palliative options
• Palliative surgical biliary bypass, percutaneous
  radiologic biliary stent placement, or endoscopic
  biliary stent placement
• Pain control (including analgesics, celiac block,
  chemoradiation)
• Treat fat malabsorption with pancreatic enzymes

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Prognosis

• Overall survival rate 4
• For patients with small cancers (lt2cm) with no
  extension beyond capsule of pancreas, complete
  surgical resection has a 5 year survival rate of
  18-24
• For patients with advanced cancers, survival at 5
  years is 1, with most patients dying within a
  year

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References

• Castillo, Carlos and Ramon Jimenez. Risk factors
  for and molecular pathogenesis of pancreatic
  cancer. Uptodate.com 2007.
• eMedicine
• MKSAP 14 Hematology and Oncology
• Michaud, et al. Physical Activity, Obesity,
  Height and the risk of pancreatic cancer. 2001
  JAMA 286(8) 921-929.
• National Cancer Institute
• Ryan, David et al. Case 20-2005. A 58 year-old
  man with locally advanced pancreatic cancer. 2005
  NEJM 352(26) 2734-2741.