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    Pancreas Cancer

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    Paulo Henrique Haß Filho
    This document provides information about pancreas cancer, including statistics, risk factors, symptoms, staging, tests, and treatment. Some key points: - The 5-year survival rate is only 6.7% and median age of diagnosis is 71. - Risk factors include smoking, obesity, diabetes, family history, and certain genetic conditions. - Symptoms often include back pain, weight loss, and jaundice. Tumors in the head of the pancreas are more likely to cause jaundice. - Staging uses the TNM system and survival ranges from 25.8% for local stage to 2.3% for distant stage disease. - Tests include blood tests, imaging like

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    Pancreas Cancer

    Uploaded by

    Paulo Henrique Haß Filho
    32 views66 pages
    This document provides information about pancreas cancer, including statistics, risk factors, symptoms, staging, tests, and treatment. Some key points: - The 5-year survival rate is only 6.7% and median age of diagnosis is 71. - Risk factors include smoking, obesity, diabetes, family history, and certain genetic conditions. - Symptoms often include back pain, weight loss, and jaundice. Tumors in the head of the pancreas are more likely to cause jaundice. - Staging uses the TNM system and survival ranges from 25.8% for local stage to 2.3% for distant stage disease. - Tests include blood tests, imaging like

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    This document provides information about pancreas cancer, including statistics, risk factors, symptoms, staging, tests, and treatment. Some key points: - The 5-year survival rate is only 6.7% and median age of diagnosis is 71. - Risk factors include smoking, obesity, diabetes, family history, and certain genetic conditions. - Symptoms often include back pain, weight loss, and jaundice. Tumors in the head of the pancreas are more likely to cause jaundice. - Staging uses the TNM system and survival ranges from 25.8% for local stage to 2.3% for distant stage disease. - Tests include blood tests, imaging like

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views66 pages

    Pancreas Cancer

    Uploaded by

    Paulo Henrique Haß Filho
    This document provides information about pancreas cancer, including statistics, risk factors, symptoms, staging, tests, and treatment. Some key points: - The 5-year survival rate is only 6.7% and median age of diagnosis is 71. - Risk factors include smoking, obesity, diabetes, family history, and certain genetic conditions. - Symptoms often include back pain, weight loss, and jaundice. Tumors in the head of the pancreas are more likely to cause jaundice. - Staging uses the TNM system and survival ranges from 25.8% for local stage to 2.3% for distant stage disease. - Tests include blood tests, imaging like

    Copyright:

    © All Rights Reserved
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    of 66

    Pancreas Cancer

    www.aboutcancer.com
    Pancreas Cancer
    Incidence (2014 Data) Deaths

    46,420 (2.8%) 39,590 (6.8%)

    The 5 year survival is only 6.7%

    Life time risk of developing this


    cancer is 1.5%
    2014 Statistics

    Male Female

    New Cases 23,530 (2.7%) 22,890 (2.8%)

    Deaths 20,170 (6.5%) 19,420 (7%)


    Age and Pancreas Cancer

    Median age is 71
    New Cases per 100,000
    Trends in Incidence and
    Survival
    Stage and Survival - SEER

    Stage Incidence Survival/5y

    Local 9% 25.8%
    Regional 28% 9.9%
    Distant 53% 2.3%
    Risk factors for pancreatic
    cancer include the following
    - Smoking
    - Obesity
    - Personal history of diabetes or chronic
    pancreatitis
    - Family history of pancreatic cancer or
    pancreatitis
    - Certain hereditary conditions
    Symptoms

    Most patients present with pain (in the back)


    weight loss or jaundice

    Tumors in the head of the pancreas are more


    likely to have jaundice,

    Those that arose in the body or tail, more


    likely pain and weight loss.
    Bile: yellowish fluid produced in the liver that aids
    in digestion of fat in the small intestine

    Liver
    Bile: passes through the common bile duct through the
    head of the pancreas on its way to the duodenum

    Liver
    Hepatic Duct
    Common Bile Duct

    Pancreatic Duct

    Duodenum
    Bile duct carries the bilirubin through the head of the
    pancreas on its way to the duodenum

    Tail of the Pancreas

    Common Bile Duct

    Common Bile Duct Body of the Pancreas


    Head of the Pancreas
    Tumors in the head of the pancreas are more likely
    to have jaundice

    Tail of the Pancreas


    Obstruct the Bile Duct
    Common Bile Duct

    Common Bile Duct Body of the Pancreas


    Head of the Pancreas

    Tumor in the Head of the


    Pancreas
    Tumors in the head of the pancreas are more likely
    to have jaundice

    Tail of the Pancreas

    Common Bile Duct

    Common Bile Duct Body of the Pancreas


    Head of the Pancreas Pancreatic Duct

    Tumor in the Head of the


    Pancreas
    Head of the Pancreas Tumor
    Blocking the pancreatic duct
    and common bile duct

    Common bile Duct


    Common Pancreatic
    bile duct
    Duct
    cancer

    Duodenum
    Tumors in the body or tail are more likely to
    present with pain or weight loss

    Tail of the Pancreas

    Common Bile Duct

    Tumor

    Common Bile Duct Body of the Pancreas


    Head of the Pancreas
    Symptoms of Pancreas
    Cancer
    Asthenia (weakness) 86 percent
    Weight loss 85 percent
    Anorexia (no appetite) 83 percent
    Abdominal pain 79 percent
    Epigastric pain (stomach) 71 percent
    Dark urine 59 percent
    Jaundice 56 percent
    Nausea 51 percent
    Back pain 49 percent
    Diarrhea- 44 percent
    Vomiting 33 percent
    Steatorrhea (fatty stools) 25 percent
    Thrombophlebitis 3 percent
    Signs of Pancreas Cancer
    Jaundice (yellow) 55 percent
    Hepatomegaly (large liver) - 39 percent
    Right upper quadrant mass 15 percent
    Cachexia (wasting) 13 percent
    Courvoisiers sign (nontender but palpable
    distended gallbladder at the right costal
    margin) 13 percent
    Epigastric mass (fell lump in stomach) 9
    percent
    Ascites (abdominal fluid) 5 percent
    Pathology
    Ductal adenocarcinoma accounts for about 85% of all
    neoplasms. And more than 95% of all pancreatic
    cancers arise from the exocrine (digestive enzymes)
    elements.

    Cancers that arise from the endocrine cells


    (neuroendocrine, islet cells) account for 5% or less
    Parts of the Pancreas
    Aorta
    Portal Vein

    Superior Mesenteric Vein

    Head Body Tail


    Cancer in the Head of the
    Pancreas

    Tail
    Body

    Head
    Location of Pancreas Cancer

    60 to 70 percent of exocrine pancreatic cancers


    are localized to the head
    20 to 25 percent are in the body/tail and
    the remainder involve the whole organ

    H = Head
    N = Neck
    B = Body
    T = Tail
    Un = Uncinate
    Location of Pancreas Cancer

    60 to 70 percent of exocrine pancreatic cancers


    are localized to the head
    20 to 25 percent are in the body/tail and
    the remainder involve the whole organ

    H = Head
    N = Neck
    B = Body
    T = Tail
    Un = Uncinate
    Tests used to evaluate and stage
    pancreas cancer
    Routine blood tests e.g. liver products
    like bilirubin
    Elevated tumor markers (CA 19-9 or
    CEA)
    MRI, CT scans, Ultrasound
    Endoscopy including endoscopic
    ultrasound or ERCP
    Laparoscopy
    Biopsy
    CA 19-9
    The reported sensitivity and specificity rates of CA 19-9 for pancreatic
    cancer range from 70 to 92, and 68 to 92 percent, respectively.

    The rates of unresectable disease among all patients with a CA 19-9 level
    130 units/mL versus <130 units/mL were 26 and 11 percent, respectively.
    Among patients with tumors in the body/tail of the pancreas, more than
    one-third of those who had a CA 19-9 level 130 units/mL had
    unresectable disease.
    Elevated CA 19-9
    Cancer

    - Pancreas
    - Biliary Cancer (gallbladder, cholangiocarcinoma,
    ampullary)
    - Hepatocellular
    - Gastric, ovarian, colorectal (less often)
    - Lung, breast, uterus (rare)

    Benign
    - Acute cholangitis
    - Cirrhosis and other cholestatic diseases (gall stones)
    Ultrasound
    study of 900 patients who underwent
    ultrasound to work up painless jaundice,
    anorexia, or unexplained weight loss

    The sensitivity for detection of all tumors in the


    pancreas was 89 percent Among the

    779 patients who were followed over time and


    established not to have developed a pancreatic
    tumor, nine had false-positive US findings
    (specificity 99 percent).
    Ultrasound

    Mass in the pancreatic head and dilated common bile duct and
    pancreatic duct
    CT

    Sensitivity of CT for pancreatic cancer depends


    on technique and is highest (89 to 97 percent)
    with triple-phase, helical multidetector row CT

    As expected, sensitivity is higher for larger


    tumors; in one study, the sensitivity was 100
    percent for tumors >2 cm, but only 77 percent for
    tumors 2 cm in size
    Endoscopy or ERCP or EUS
    ERCP or Endoscopic retrograde
    cholangiopancreatography

    Scope

    Duodenum
    ERCP

    Try to
    get into
    the duct
    system
    ERCP
    Inject dye into
    the duct system
    and look for
    compression
    ERCP

    Sensitivity of 92 percent and Specificity of 96 percent for


    diagnosing cancer of the pancreas by ERCP

    ERCP provides an opportunity to collect tissue samples


    (forceps biopsy, brush cytology) for histologic diagnosis.

    However, the sensitivity for detection of malignancy


    (approximately 50 to 60 percent) is lower than that of
    endoscopic ultrasound (EUS)-guided FNA (sensitivity 92
    percent)
    EUS
    endoscope
    (Endoscopic
    Ultrasound
    Ultrasound
    Tip

    Detailed
    image of
    this area
    EUS or Endoscopic
    Ultrasound
    A: met to the
    pancreas head

    B: lymphoma in
    tail

    C: endocrine
    tumor in isthmus

    D: insulinoma in
    body

    From
    Endoscopic
    Ultrasound
    2014:3
    EUS used for pain relief with
    celiac plexus neurolysis
    Endoscopic Placement of a
    Stent

    stent
    cancer

    stent
    scope
    duct

    pancreas
    CT Scan Pancreas Cancer
    CT Scans
    CT or PET Scan
    PET Scans
    TNM Stage: how far has the
    cancer spread, T (tumor) N
    (nodes) M (mets) combine all 3
    to get Stage
    Stage IA (T1aN0M0)
    Stage IB (T2N0M0)
    over 2cm, limited to pancreas
    Stage IIA (T3N0) beyond the
    pancreas
    Stage IIB (T1-3N1M0)
    Stage III (T4) Unresectable
    Cancer has spread to the major blood
    vessels near the pancreas. These include
    the superior mesenteric artery, celiac axis,
    common hepatic artery, and portal vein.
    Stage IV -
    Metastasis
    Lung
    Liver
    Cancer in
    Pancreas
    Peritoneal
    Cavity
    NCDB Statistics

    Stage Incidence Survival/5y

    I 8.5% 20%
    II 23% 10%
    III 14% 2.5%
    IV 54% 1.6%
    Survival by Stage
    1.2

    0.8

    0.6

    0.4

    0.2

    0
    0 year 1 year 2 year 3 year 4 year 5 year

    Stage I Stage II Stage III Stage IV


    Survival
    Surgery offers the only cure but only 10-20% are
    candidates for resection and even in this group
    the 5 year survival is only 20% and the median
    13 to 20 months

    Locally advanced the survival is 8 to 14 months

    Up to 60% already have metastases and a


    median survival of only 4 to 6 months
    nccn.org
    nccn.org/patients
    Summary of Treatment
    1. Resection is the only chance for a cure, and
    resectable patients show undergo surgery
    without delay followed by adjuvant therapy
    2. Borderline resectable patients may benefit
    from neoadjuvant therapy and then surgery
    3. Unresectable patients may benefit from
    chemotherapy or chemoradiation
    4. Metastatic disease may benefit from
    chemotherapy or other palliative treatments
    Allen Oldfather Whipple (1881-
    1963)

    Surgery professor at Columbia


    where he developed the resection
    for pancreas cancer in 1935 now
    called the Whipple Procedure
    Summary of Treatment
    1. Resection is the only chance for a cure, and
    resectable patients show undergo surgery
    without delay followed by adjuvant therapy
    2. Borderline resectable patients may benefit
    from neoadjuvant therapy and then surgery
    3. Unresectable patients may benefit from
    chemotherapy or chemoradiation
    4. Metastatic disease may benefit from
    chemotherapy or other palliative
    treatments
    Chemotherapy
    Chemotherapy for Metastatic
    Pancreas Cancer

    FOLFIRINOX (oxaliplatin (Eloxatin),


    irinotecan (Camptosar) , leucovorin,
    fluorouracil)
    Gemzar (gemcitabine) + Abraxane
    (albumin bound paclitaxel)
    Gemzar + erlotanib (Tarceva, EGFR
    drug)
    Chemotherapy
    Survival Comparisons in Months

    5-FU 4.4 Gemzar 5.6

    Gemzar 6.8 FOLFIRINOX 11.1

    Gemzar 6.7 Gem + Abraxane 8.7


    Survival with Metastatic
    Pancreas Cancer

    FOLFIRINOX

    Gemzar

    Months

    NEJM 2011:364:1817
    Survival with Metastatic
    Pancreas Cancer

    Gemzar + Abraxane

    Gemzar

    Months

    NEJM 2013;369:1691
    Pancreas Cancer
    www.aboutcancer.com

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