CASE PRESENTATION

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CASE PRESENTATION

• CC Jaundice
• HPI 64-yr-old man
• 4 wk h/o anorexia 15 lb wt loss
• 2 wk h/o
• pruritus
• dark urine
• abdominal pain, midepigastric, dull, constant
  with radiation to the back
• 2 days earlier a family members notes jaundice

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CASE PRESENTATION

• PMH DM, type 2 (dxd 6 yrs ago)
• PSH None
• Meds glyburide
• ALL NKDA
• SH Married. No EtOH or tobacco
• FH No malignancies

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CASE PRESENTATION

• Physical Exam
• Vitals 120/83 65 12 AF 176 lbs
• Gen NAD.
• Heent Icteric. OP nl.
• Neck Supple. No LAD.
• Lungs CTA.
• Heart RRR w/o m/r/g.
• Abd NABS. Tender MEG. Palpable non- tender
  gallbladder.
• Ext No c/c/e.

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CASE PRESENTATION

• Laboratory Data
• TBili 8.5
• Alk phos 350
• AST 78
• ALT 90
• Albumin 3.0
• Hgb 10.5

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PancreaticobiliaryCancer

• Rajeev Jain, M.D.

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2005 Estimated US Cancer Cases
Men710,040
Women662,870
32 Breast 12 Lung and bronchus 11 Colon and
rectum 6 Uterine corpus 4 Non-Hodgkin
lymphoma 4 Melanoma of skin 3
Ovary 3 Thyroid 2 Urinary bladder
2 Pancreas 21 All Other Sites
Prostate 33 Lung and bronchus 13 Colon and
rectum 10 Urinary bladder 7 Melanoma of
skin 5 Non-Hodgkin 4
lymphoma Kidney 3 Leukemia 3 Oral
Cavity 3 Pancreas 2 All Other Sites 17
Excludes basal and squamous cell skin cancers
and in situ carcinomas except urinary
bladder. Source American Cancer Society, 2005.
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Pancreas

• Acinar cells 80
• Ductal cells 10-15
• Endocrine cells 1-2

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Pancreatic Cancer

• Endocrine
• 1 to 2
• Exocrine
• gt 95
• 85 to 90 ductal origin
• Head 60-70
• Body 5-10
• Tail 10-15

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Pancreatic CancerWHO Classification - Exocrine

• Malignant
• Ductal adenocarcinoma
• Osteoclast-like giant cell tumor
• Serous cystadenocarcinoma
• Mucinous cystadenocarcinoma
• Intraductal papillary mucinous carcinoma
• Acinar cell carcinoma
• Pancreatoblastoma
• Solid-pseudopapillary carcinoma
• Miscellaneous carcinoma

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Pancreatic Cancer ACS 2005 Estimates
www.cancer.org
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Pancreatic CancerRisk Factors

• Tobacco (RR 1.5 3)
• Family history (7-10)
• 1st degree relative RR 3-5
• Familial syndromes
• Hereditary pancreatitis (AD, cationic trypsinogen
  gene)
• 40 by age 70, up to 75 if paternal
• Peutz-Jeghers
• Von Hippel-Lindau
• Familial atypical multiple-mole melanoma (FAMMM)
• Ataxia-telangiectasia
• FAP, HNPCC
• Chronic pancreatitis (RR up to 16)
• Diabetes mellitus, type II (RR 2 if DM present gt
  5 yrs)
• Others Obesity, inactivity, diet

Michaud DS. Gastrointest Endosc 200256S195-200.
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Pancreatic Carcinogenesis

• Activation of oncogenes
• Inactivation of tumor suppressor genes
• Defects in DNA mismatch repair genes

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Pancreatic CancerPresentation

• Symptoms signs
• Jaundice, pruritus, acholic stool
• Abdominal pain
• Back pain
• Weight loss, anorexia, nausea vomiting
• Curvoisiers sign palpable non-tender
  gallbladder
• Acute pancreatitis
• New onset diabetes
• Pancreatic exocrine insufficiency

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Pancreatic CancerDiagnostic Evaluation

• Laboratory
• Tumor markers
• Radiology
• Computed Tomography Scan
• Magnetic Resonance Imaging (MRI/MRCP)
• Positron Emission Tomography
• Percutaneous Transhepatic Cholangiography (PTC)
• Endoscopy
• Endoscopic Retrograde Cholangiopancreatography
  (ERCP)
• Endoscopic Ultrasound (EUS)

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CA 19-9 Tumor-Associated Antigen

• Synthesized by pancreatic and biliary ductal
  cells
• Lewis A blood group
• 5 of population is Lewis A-B- and cannot
  synthesize CA 19-9
• Upper limit of normal 37 U/ml
• Sensitivity 81
• Specificity 90
• False elevation cholangitis
• CA 19-9 gt 1000 predicts unresectability
• Predicts recurrence

Steinberg W. Am J Gastroenterol 199085350-5.
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Pancreatic CancerCT Scan

• Pancreas protocol
• Thin cuts
• PO/IV contrast
• First (pancreas) phase
• 40s after IV contrast
• Max. enhancement of normal pancreas
• Second (portal vein) phase
• 70s after IV contrast
• Liver metastases
• Tumor involvement of portal mesenteric veins

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Pancreatic CancerERCP

• Diagnostic
• Pancreatic ductal abnormalities
• Tissue (brushings)
• Sens 18-60, Spec 99
• Therapeutic
• Biliary drainage
• Plastic stent
• Metal stent

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Pancreatic CancerERCP
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Endoscopic Ultrasound

• Developed to overcome limitations of
  transabdominal ultrasound
• intervening structures
• limited resolution
• Transducer placed at distal end of side-viewing
  endoscope

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Endoscopic Ultrasound
Radial
Linear
100
360
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Pancreatic Mass with Vascular Involvement
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Pancreatic CancerEndoscopic Ultrasound

• Tumor staging
• more accurate than helical CT in small lesions
  and assessing local extent, lymph nodes,
  vascular invasion
• CT better for distant metastases
• better than angiography
• ? MRI, MRCP, PET scan
• Diagnostic Fine Needle Aspiration (FNA)
• Sensitivity 85
• Specificity 99

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Percutaneous Transhepatic Cholangiography (PTC)
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Pancreatic Cancer
SUSPICION OF PANCREATIC CANCER
Helical CT Scan
Pancreatic head tumor lt 2 cm
Tumor of body or tail of the pancreas
Pancreatic head tumor gt 2 cm
No tumor
ERCP EUS
Laparoscopy with cytology of washings
if
if -
Surgical exploration for resection
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Pancreaticoduodenectomy
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Pancreatic CancerPalliative Issues

• Jaundice
• ERCP, PTC, or surgery
• Pain
• Radiation therapy
• Celiac axis neurolysis
• Surgical, fluoroscopic- or EUS-guided
• Duodenal obstruction
• Surgery or metal stent

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Endoscopic Stents

• Plastic stents polyethylene
• Drainage prior to surgery
• Up to 11.5 Fr
• Life span lt 3 months
• 100
• Metal stents self-expanding metal stents (SEMS)
• Palliative
• 10 mm or 30 Fr
• Longer patency
• Life span gt 3 months
• 1,000

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ERCP Stent v Surgical Bypass Palliation of
Biliary Obstruction in Pancreatic Cancer
Flamm CR et al. Gastrointest Endosc
200256(6)S218-25.
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Plastic v Metal Stent Palliation of Biliary
Obstruction in Pancreatic Cancer
Levy MJ et al. Clin Gastroenterol Hepatol. 2004
Apr2(4)273-85.
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Duodenal Obstruction
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Duodenal Obstruction
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Screening for Pancreatic Cancer
No guidelines or recommendations Studies in
progress Univ. Washington Johns Hopkins

• Who
• High-risk individuals
• When
• Age 40 yrs or 10 yrs younger than the youngest
  family member with PC
• How
• Serology Genetic and protein markers
• Radiology CT, MRI/MRCP
• Endoscopy EUS, ERCP

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Pancreatic Cancer AJCC Staging
Primary Tumor (T) T1 Limited to pancreas, lt 2
cm T2 Limited to pancreas, gt 2
cm T3 Extension into duodenum,
CBD T4 Extension into vessels (not
splenic), stomach, spleen, or colon Regional
Lymph Nodes (N) N0 None N1 Regional nodal
metastases Distant Metastases (M) M0 None M1
Distant metastases
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Pancreatic Cancer AJCC Staging
Stage T N M
I 1 0 0
2 0 0
II 3 0 0
1 1 0
III 2 1 0
3 1 0
IVA 4 any 0
IVB any any 1
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Biliary Tract Cancer

• Gallbladder
• Extrahepatic bile duct
• Ampulla of Vater

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Gallbladder Cancer

• 2.5 cases per 100,000
• 5th most common GI cancer
• 6,500 deaths/year
• MF 13
• Risk factors
• Gallstones
• Porcelain gallbladder
• Chronic typhoidal carrier
• Presentation
• Pain, jaundice
• 1-2 of resected gallbladders
• 5 YR Survival 5

• Highest incidences (7-20/100,000)
• Native Americans (North South)
• Poland
• Northern India

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Cholangiocarcinoma

• 1 case per 100,000
• Slight MgtF
• Risk factors
• Primary sclerosing cholangitis (PSC)
• Choledochal cysts
• Clonorchis sinensis
• Hepatolithiasis
• CBD stones
• Thorium dioxide (Thorotrast)

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Cholangiocarcinoma
MRCP of PSC

• Presentation
• Obstructive jaundice
• Diagnosis
• Tumor markers
• CA 19-9 (85)
• CEA (35)
• CA 125 (30-50)
• ERCP/MRCP
• CT scan
• Treatment
• Surgery
• Palliation
• Biliary drainage
• 5 YR Survival 5

ERCP
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Bismuth Classification
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Ampullary Cancer

• 3 cases per 1 million
• Risk factors
• FAP
• Peutz-Jeghers
• Presentation
• Jaundice
• Silver stool
• Diagnosis/Staging
• EGD, CT, EUS, ERCP
• Treatment Surgery
• 5 YR Survival 25 40

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Outcome of Patients after Pancreaticoduodenectomy
Operative Mortality Rate () Operative Morbidity Rate () Median Survival (mos) 5-Year Survival Rate ()
Pancreatic Cancer 3-15 27-40 11-18 6-26
Biliary Tract Cancer 1-11 24-44 22-33 13-43
Ampullary Cancer 3-15 25-59 38-49 33-48
Duodenal Cancer 1-6 57-64 86 32-60
Sarmiento JM, et al. Surg Clin North Am 2001.
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