Pancreatic

Neoplasm
5/24/06
Brent White
Richard Barth

Facts About Brent &

Georgia

Born in Durham, NC
4/8/74
My family moved to
Columbus, Georgia when I
was 6 weeks old
Georgia is known as The
Goober State
Goober=Peanut
Georgia produces quite a
few peanuts, growing 42%
of peanuts grown in the
US

Overview

During 2006, estimated 32,300 people

will die in the US of pancreatic cancer
Fourth and fifth most common cause of
cancer deaths in men and women in the
US respectively
Peak incidence in age 60-80
African Americans with slightly higher
incidence compared with Caucasians

Types of Pancreatic
Neoplasms

Broadly speaking, there are three basic

types:
Ductal adenocarcinoma >90% of
pancreatic cancers with a 4% 5-year
survival (worst of any cancer)
Neuroendocrine tumors aka islet-cell
tumors, rare
Cystic neoplasms account for <1% of
pancreatic cancers

Clinical Scenario #1
Adenocarcinoma of the
Pancreas

70yo female with PMH of HTN who

developed jaundice without
significant abdominal pain, no fever
Bilirubin 12
No significant complaints of
abdominal pain

Clinical Scenario #1
Adenocarcinoma of the
Pancreas

What are typical symptoms of pancreatic

CA?

Abdominal pain->pain can suggest neural

plexus, tail lesion, unresectability, poor
prognosis
Anorexia
Weight loss
Jaundice
Pruritis ->biliary obstruction
Steatorrhea->pancreatic duct obstruction

Risk Factors for Pancreatic

Cancer?

Firmly linked to cigarette smoking

No clear dietary factors
Increased BMI associated with
increased risk
Occupational exposures to amines
(chemistry, hairdressing, rubber
work) associated with increased risk

Risk Factors for Pancreatic

Cancer

Previous epidemiology identified

chronic pancreatitis as a risk factor

May actually be EtOH, smoking, and a

degree of selection bias instead of
pancreatitis

Familial excess of pancreatic cancer,

hereditary cancer syndromes,
hereditary pancreatitis, BRCA-2
mutations all associated with
increased risk of pancreatic cancer

Adenocarcinoma of the
Pancreas: Workup

70yo female with painless jaundice...

What would widely be regarded as
the single most useful imaging study
in this patients workup?

CT

Adenocarcinoma of the
Pancreas: CT scan

CT can confirm pancreatic cancer with

a sensitivity of 85-95% (sensitivity is
limited by smaller tumor size)
Other than the presence of a pancreatic
mass, what else can you determine
from CT scan?

PRESENCE of METASTASES (along with

CXR)

RESECTABILITY

Adenocarcinoma of the
Pancreas: CT scan

What makes a pancreatic mass likely

resectable?
No evidence of extrapancreatic disease
Evidence of nonobstructive superior
mesenteric-portal vein confluence
No evidence of direct tumor extension to
the celiac axis and SMA
EUS, laparoscopy are universally regarded
as useful adjuncts to CT, not as essential
however

Adenocarcinoma of the
Pancreas: CT scan

Borderline Resectable lesions

include:
SMV occlusion of a short segment
(open vein proximally and distally)
Body and tail lesions with + celiac,
para-aortic nodes in the vicity
Tumors briefly involving the IVC
may be borderline

Adenocarcinoma of the
Pancreas: CT scan

Adenocarcinoma of the
Pancreas: Workup

The mass appears borderline

resectable per these criteria
Now what?
GI

consultation for ERCP

and EUS!

Pancreatic Cancer:
Endoscopic Adjuncts

ERCP can be utilized to:

detecting small tumors not visualized on CT (irregular

solitary duct stenoses >1cm long, abrupt cutoff of
main pancreatic duct, or panc and bile duct
obstruction)
palliating biliary obstruction
brush cytology of the pancreatic duct has fair
sensitivity (70%) but excellent specificity

EUS can be utilized to:

aid in diagnosis and characterization of lesion

obtain tissue biopsy; may be associated with lower
risk of peritoneal seeding c/w percutaneous approach

Pancreatic Cancer:
Endoscopic Adjuncts

ERCP picture

Pancreatic Cancer:
Serum Markers

Is there a role for serum markers? If so,

what?

CA 19-9 is a sialylated Lewis A blood group antigen

commonly expressed and shed in pancreatic and
hepatobiliary disease, not tumor specific
This antigen, when significantly increased, can assist in
differentiating between pancreatic adenocarcinoma and
inflammatory pancreatic disease
decrease in serial CA 19-9 correlates with survival of
pancreatic patients after surgery or chemotherapy
Debatable as to whether this is useful as early treatment
of recurrences have not been shown to improve
outcomes

Pancreatic Cancer
Staging

Though TNM staging exists, we can

roughly simplify to:
local/resectable, median survival 17
months
locally advanced and unresectable,
median survival 8-9 months
metastatic disease, median survival of
4-6 months

Pancreatic AdenoCA Algorithm

Pancreatic Cancer:
Neoadjuvant Therapy

This 70yo female has borderline

resectable features, has been stented
to answer obstructive jaundice via
ERCP with EUS demonstrating a
positive adenocarcinoma
Is there any role for neoadjuvant
therapy for this patient? If so, what
sort of regimen and with what
objectives?

Pipas, Barth et al.

24 patients with pancreatic adenocarcinoma

Inclusion criteria: biopsy-proven
adenocarcinoma of pancreas (Stage I-III),
age>18yo, Karnofsky of >70%, Creatinine<2,
WBC >3000, Hgb >10g/dL, Plts >100,000
No history of chemo/XRT or malignancy
Treatment consisted of docetaxel 65mg/m2 IV
over 1 hour and gemcitabine 4000mg/m2 IV over
30 minutes on days 1, 15, 29. On Day 43, XRT at
50.4 Gray with gemcitabine 50mg/m2 IV over 30
minutes biweekly for 12 doses

Pipas, Barth et al.

All but one of 24 patients completed 12 week

course of therapy
Grade 3 and 4 toxicities common, but
manageable
No tumor progression, 12 responded to therapy
with one radiographic CR
50% of patients had radiographic response,
17/24 patients underwent resection after
therapy
Of 17 resection patients, 13 (76%) with negative
margins

Pipas, Barth et al.

Adenocarcinoma

70yo female undergoes

docetaxel/gemcitabine followed by
gemcitabine with XRT and appreciable
response is seen on repeat CT
Whipple Operation
Utility to pylorus preservation?
Extended lymphadenectomy?
Does type of pancreatic anastamosis matter?
Do stents decrease pancreatic fistulas?

Case #2

28yo surgical resident was golfing,

badly. Suddenly, according to his
partners, he began acting crazy
and drove the golf cart wildly around
the green, through a sandtrap and
into a small creek. He was
incoherent when he was brought to
the ER and found to have a serum
glucose of 32.

How is insulinoma
diagnosed?

Whipples Triad:

Definitive test is 72-hour fast with

measurement of insulin and glucose

symptoms of hypoglycemia during fasting or exercise

serum glucose <45mg/dL during symptoms
relief of symptoms with administration of glucose

75% of patients develop symptoms and GB<40 within 24

hours
insulin:glucose ratio >0.4 is indicative of insulinoma

Elevated c-peptide proinsulin levels are

confirmatory along with screening for
antiinsulin antibodies, sulfonylureas

What percent are

malignant?

10% are malignant, indicated by

metastases
Metastases usually to regional
peripancreatic lymph nodes, liver
generally sporadic, solitary, benign,
<2cm occurring in equal distribution
throughout the pancreas

How are insulinomas

localized?

Non-invasive preoperative imaging

studies fail to localize 30-35% of
insulinomas
CT/MRI, etc. generally reserved by
most endocrine surgeons to r/o
hepatic metastases
Intraoperative U/S and palpation are
the GOLD standard for finding an
insulinoma, 96-100% sensitivity

What is proper operation

for insulinoma?

Generally wide Kocher maneuver, superior

and inferior pancreatic border mobilization,
medial reflection of the spleen
Bimanual palpation with U/S
Enucleation of the lesion
Secretin can assist in identifying pancreatic
duct leak after enucleation completed
What about lesion in pancreatic head?
Need to monitor glucose levels q15 minutes
until lesion out

Case #3

A patient has a gastric ulcer

diagnosed endoscopically and is
treated with Cimetidine. One month
later, the ulcer is still present
despite treatment.

How is ZE diagnosis
made?

Elevated serum gastrin level, elevated

basal acid secretory rate both only suggest
possible gastrinoma
Secretin stimulation test
discontinue acid-inhibitory medication
basal serum gastrin levels
2 U/kg of secretin IV bolus, then serum gastrin
measured at 2, 5, 10, and 20 minutes later
Positive response is gastrin >200pg/mL above
basal level

How would you control

gastric acid secretion?

Proton pump inhibitor titrated to

achieve non-acidic gastric pH

Where are gastrinomas?

How would you localize
it?
Most are found in the duodenum, pancreas,

or lymph nodes near the head of the

pancreas, 10% of the time they are heart,
liver, bile ducts, ovary, etc.
Localization with somatostatin receptor
scintigraphy (SRS) (only 30% of
gastrinomas <1.1cm)
SRS and EUS can, in tandem, improve
detection of small gastrinomas within the
wall of the duodenum

At operation, what is the

likelihood of finding
metastatic tumor?

Metastatic tumor to liver is found in

5-14% of cases, nodal metastases in
50% of patients

Where are most

gastrinomas found?

Gastrinoma triangle is
where most tumors are
found (70-90%)
Tumor detection can be
improved via palpation,
IOUS, extended Kocher
maneuver,
transillumination of the
duodenum, and
duodenotomy

Hypercalcemia and
Gastrinoma

If patient has MEN-1 (hyperparathyroidism,

pituitary adenoma, islet-cell tumor), can they
be cured with surgery for gastrinoma?
Seldom can biochemical cure be achieved due to
multicentric nature of disease in MEN-1
93% of patient with MEN-1 alive 15 years after
diagnosis, if they are on PPIs and have no liver
mets
some advocate surgical treatment only in sporadic
form of disease; others propose operating on MEN1 gastrinomas only when 2.5-3cm in size in order to
reduce possibility of metastases