PANCREAS

Dr Sigid Djuniawan , SpB

TUMOURS OF THE PANCREAS

The tumours of the pancreas can be

-
A. Non-Endocrine neoplasms
B. Endocrine neoplasms
 NON-ENDOCRINE NEOPLASMS:

 Benign non-endocrine neoplasms of

pancreas. Includes:-
(adenoma, cystadenoma, lipomas, fibromas,
haemingoma, lymphangioma and neuromas).
They are extremely rare and no clinical
significance unless they become palpable or
give pressure to adjacent structures and
cause symptoms. Can be solid or cystic or
both. The diagnosis should be made after
exclusion of more frequent malignant
tumours.
 Malignant non-endocrine neoplasms. The
most common are:-
1. Ductal adenocarcinoma Exocrine
2. Cystadenocarcinoma cell of
pancreas
NOTE: Periampullary carcinoma is term used for
juxta-pancreatic carcinomas. They are three
forms:-
 Carcinoma of the ampulla
 Carcinoma of the lower CBD
 Duodenal carcinoma
ENDOCRINE NEOPLASMS:
These are less common than non-endocrine
tumours and generally benign and sometimes
multiple. They includes:
 Insulinoma
common
 Glucogonomas
 Others:
- Gastrinomas
- Somatostatatinomas
- Vipomas (Vasoactive Intestinal
Polypeptide)
EVALUATION OF PANCREATIC NEOPLASMS:
 History
 Clinical Examination
 Investigations

The specific investigations:-

 Ultrasound Scan  Histology & cytology
 CT Scan  Angiography
 MR Imaging  Laparoscopy
 ERCP
 NON-ENDOCRINE NEOPLASMS: (ADENO-
CARCINOMA OF PANCREAS)

 Ductal adeno carcinoma (arising in the

exocrine part of pancreas) account for
90% of pancreatic tumour 2/3rd located in
the head of pancreas.

Cystadenocarcinoma and endocrine

tumour account for most of the remains of
malignancy.
Contn…
 The exact causative factors
responsible are unknown. The peak
incidence in the 6th and 7th decade and
more in men than women.
The predisposing factors are:
 Diet (high protein & high fat)

 Smoking

 Exposure to industrial carcinogens

Contd…
 Spread of pancreatic tumours:
A. Local Invasion
B. Lymphatic
C. Blood

D. Via peritoneal & omental

causing ascites
 CLINICAL FEATURES:

 The diagnosis of pancreatic cancer

varies from the simple and clinically
obvious to the most difficult and
almost impossible the initial
symptoms and signs depend on the
site and extent of the pancreatic
cancer.
 Modes of presentation:
 Weight loss
 Pain
 Jaundice
 Steatorrhoea
 Diabetes Mellitus
 Acute Pancreatitis
 Malignant Ascites
 Gastric Outlet Obstruction
 Approach to Investigations:
(Selective Investigations)
 Ultrasound Scan
 C.T. Scan
 MR Imaging Scan
 ERCP
 Histology & Cytology
 Angiography (Coeliac, Superior -
Mesenteric)
 Laparoscopy
DELAY IN DIAGNOSIS:
 Over 90% of patient with pancreatic cancer
present in the late stage of their disease. At
time no chance of cure.
 The factors responsible for late diagnosis
A. Tumour is asymptomatic in the early
stage.
B. Patient delay.
C. Physician delay.
D. The patient may not have ready and easy
access to competent diagnostic centre.
MANAGEMENT OF PANCREATIC CANCER:

A. Surgical Treatment

B. Non Surgical Treatment

SURGICAL TREATMENT:

 Pancreatic Cancer is essentially

incurable since metastasis occurs at
such early stage. Any treatment must
be regarded as palliative.
 Surgical Options:
 For curative surgical treatment of
cancer in the head of pancreas the
optims are available:
A. Whipple operation (Pancreatico-
duodenectomy)
B. Pylorus Preserving
Pancreaticoduodenectomy
C. Total Pancreatectomy
Contn…
 Palliative Surgical Treatment
(Surgical Bypass)

 For tail of the pancreas

(Distal pancreatectomy)

 Body of the pancreas

(Distal + removal of the body of
the pancreas)
 Pre-operative preparation of the patient
for major surgery:
1. All jaundiced patients must be kept in
good state of nutrition and hydration.
2. Blood clotting deficiencies must be
corrected.

3. Cardio pulmonary functioning carefully

assessed.

4. Drainage procedure consider in certain

cases.
NON-SURGICAL TREATMENT:
The following options available:
(Pallative procedure for non operable cases)
 Percutaneous coeliac ganglion blockade.
(For pain)
 Stent to compress bile duct.
 Percutaneous transhepatic drainage or
stenting.

 Combination of chemotherapy and

radiotherapy may become alterative in
the future.
FUNCTIONING ENDOCRINE TUMOURS OF
THE PANCREAS:

 These are much less common than

adeno carcinoma. The beta cell
tumours secrete (Insulin) and called
INSULINOMAS. Another functioning
tumour secrete (Gastrin) called
GASTRINOMA which come from the
islets which cannot be classified
into either alpha or beta (non-beta).
 Other tumours are:
a. Vipoma (Werner-Morrison syndrome,
Pancreatic cholera)
b. Somastatinoma
c. Glucagonoma
d. HP Poma (Human Pancreatic
Polypeptide tumours)

 Slow growing and therefore carry much

better prognosis.
INSULINOMA:

 The commonest islet cell tumour and

arise from the beta cell and situated
anywhere on the surface or within the
substance of the pancreas.

 Most tumours are benign adenomas but

15% are low grade carcinomas and
secrete (insulin).
CLINICAL FEATURES:

Whipple described a triad of features

which typify the (insulinomas):

1. Fasting produces fainting.

2. During these “attacks” there is

hypoglycaemia.

3. The attacks may be relieved by

ingestion of glucose.
 INVESTIGATIONS:
1. Measurement of blood sugar in an attack.

2. Overnight fasting serum glucose and insulin

level (before & after overnight). Insulin
level are estimated by radio- immunoassay.

3. Pre-operative localization of the tumour very

important identification at operation can be
difficult.
[Combination CT Scan and selective
angiography]
TREATMENT:
1. If the tumour localized surgical resection is
the TR of choice also this apply to metastases.

2. If the tumours not localized during surgery

(Intra operative USS can be done to localize the
tumour) than resected.

3. Sub total distal resection for multiple tumours

is appropriate.

Contn…
4. With negative exploration it is appropriate to
perform pancreatectomy distal to the superior
mesenteric vessels.

5. The Hypoglycemic attacks may be relieved by

diazoxide or streptazotocin.
GASTRINOMA: (Zollinger-Ellison
Syndrome)
The tumour arising from the islets cell of
langhans in the pancreas and in the duodenal
wall.

The majority (60%) of these tumours are

malignant. They may be associated with (MEN
1) which are Parathyroid Hyperplasia, and
Pituitary Adenoma. Gastrinoma give rise to ZE
Syndrome which consist of triad
(hypersecretion of gastric acid, severe peptic
ulceration and the presence of non-beta cell
tumour of the pancreas or duodenum).
CLINICAL FEATURES:

 The disease present as peptic ulcer

disease in over 90%. They have typical
pain more severe and less response to
medical treatment.

 Co-existing diarrhoea.

 All complications of peptic ulcer disease

are present in (ZE-Syndrome) as acute
haemorrhage, perforation and recurrent
ulceration.
 THE DIAGNOSIS OF ZE-SYNDROME:

 Severe peptic ulcer disease doesn’t

respond to treatment.

 Multiple peptic ulcers or ulcers in

unusual locations such as the distal
duodenum or jejunum.

 Peptic ulcer disease associated with

diarrhoea.
Contn…
 Recurrent peptic ulcer disease
following in acid reducing operation
(surgery).

 Peptic ulcer is associated with MEN- 1

Syndrome.

 Marked elevation of serum gastrin.

TREATMENT:

 Medical therapy for control of the acid

hypersecretion in patient with ZE-
Syndrome Omprazole considered the
antisecretory drug of choice for all
gastrinoma patients.
 Surgical Treatment:
 Tumour excision.
 Total gastrectomy.
 Patient with metastases should have
medical therapy if fail total
gastrectomy.
 Gastrinoma patient with MEN 1
Syndrome and documented
hyperparathyroidism should have
parathyroid surgery performed prior to
removal of gastrinoma.