CARCINOMA OF PANCREAS

• Carcinoma of pancreas is the 4^th leading cause of cancer in males.

  

  

RISK FACTORS-

1. Demographic, environmental factor

• Smoking/ tobacco
• Obesity
• Exposure to benzidine, DDT

     2. Molecular carcinogenesis

• MC mutation- KRAS
• MC inactivated tumour suppression gene- p16/ CDKN2A

     3. Genetic and medication factors-

• Hereditary pancreatitis
• Chronic pancreatitis
• Peutz- Jegher’s syndrome (MC risk), Gardner’s syndrome
• HNPCC
• Ataxia telangiectasia
• Familial breast- ovarian cancer syndrome
• DM
• Hemochromatosis

 

PATHOLOGY-

• Periampullary refers to carcinoma arising from ampulla of Vater, duodenal mucosa or lower end of common bile duct.
• MC tumour of pancreas is ductal adenocarcinoma with the most common site being the head of the gland.
• Cystic tumours are mucinous and serous

a) Serous cystadenomas are benign seen in older women.

b) Mucinoustumors- have malignant potential. They are-

i) Mucinous cystic neoplasm (MCN)

• Occurs in perimenopausal women
• Present in pancreatic body or tail
• It contains histologically ovarian type stroma

ii) Intraductal papillary mucinous neoplasm (IPMN)

• Seen in old men
• Common in pancreatic head
• More tendency to be malignant.

   

• Proliferative lesion in the pancreatic ducts –> invasive ductal adenocarcinoma termed as pancreatic intraepithelial neoplasm or PanIN.
• Solid pseudopapillary tumours are rare malignancy seen in childbearing age women.

  

CLINICAL FEATURES-

• MC site- head> body > tail
• Seen in 6^th to 7^th decade
• More common in males
• Prognosis is bad
• Nausea vomiting, weight loss and abdominal pain
• Back pain (retroperitoneal infiltration)
• Jaundice (MC)
• Trousseau’s sign (thrombophelbitis migrans)
• Migrating thrombophelibitis of the legs occurs in visceral malignancies
• It is superficial and affects the leg veins
• Anaemia
• Hard, irregular fixed mass
• Duodenal obstruction

  

INVESTIGATIONS-

1. Pancreatic head tumors – contrast enhanced CT

• Detects a tumor
• Diagnois required prior to surgery

    3. CA 19- 9 (carbohydrate antigen)

• Increase in 80% tumors
• Tumour marker of pancreas to detect Pancreas carcinoma

     4. ERCP- small ampullary lesion

• Double duct sign
• Scrambled egg appearance

    5. Barium meal X-ray

• Rose thorn appearance in hypotonic duodenography
• Reverse 3 sign- periampullary carcinoma
• Pad sign (widened C loop of duodenum) – carcinoma head

  

TREATMENT-

1. Carcinoma head of pancreas (ampulla)-

• Pylorous preserving pancreatico
• Duodenectomy
• Whipple’s procedures

     2. Carcinoma of body/ tail

• Distal pancreatomy with en- bloc splenectomy

1. Multifocal tumor- total pancreatectomy (main duct IMPN)
2. Radiotherapy
3. Gemcitabine + erlobinib- HER1/ EGFR tyrosine kinase inhibitor for metastatic disease

• Stage wise survival after treatment-

 

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