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PANCREATIC TUMOUR

Oleh : dr. Hans Marpaung, SpB,

FICS

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ANATOMY AND PHYSIOLOGY

The pancreas is large central retroperitoneal glandoverlying vertebral column in the supracoliccompartment of the abdomen.

It has a complex vascular supply andvenous/lymphatic draining and is surrounded by thedoudenum and upper jejunum.

It has two components :

Exocrine ( Trypsinogen, proelastase, amylase, lipase,phospholipase A)

Endocrine : ( hormones essential for metabolism)

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Chapter 19

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The endocrine pancreas consists of the islets ofLangerhans, which comprise four recognized cell

types.

A cells (cells): synthesize, store and

secrete glucagon.

B cells ( cells): synthesize, store and

release insulin;

also form islet amyloid-associated

polypeptide and pancreastatin.

D cells: secrete somatostatin andprobably gastrin.

F cells: secrete pancreatic polypeptide

(HPP).

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TUMOURS OF PANCREAS

Definition :

Pancreatic adeno carcinoma :Malignant lession of thehead,body,tail of the pancreas

Periampullary carcinoma :arise around the ampulla of Vaterand include tumours of the pancreas, doudenum, distal bileduct and the ampulla itself.

Endocrine panreatic tomours :Cause variety of syndromessecondary two the secretion of active peptides

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CLASSIFICATION of PANCREATIC NEOPLASMA

Cel l of or ig in Benign Mal ignant

Ductal cell Adenoma Adenocarcinoma

Cystadenoma Cystadenocarcinoma

Acinar cell Acinar cell adenoma Acinar cell carcinoma

Acinar cystadenoma Acinar cystadenocarcinoma

Mesenchymal cell Fibroma Fibrosarcoma

Leiomyoma Leiomyosarcoma

Islet cell Insulinoma Insulinoma

Glucagonoma Glucagonoma

Gastrinoma Gastrinoma

Somatostatinoma Somatostatinoma

VIPoma VIPoma

Islet adenoma Nonfunctioning islet cell

carcinoma

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Tomours of exocrine pancreas

Epidemiology : Male/female ratio 2 :1

Age 5070 years Incidence of pancreatic carcinoma is increasing in the

western world

Aetiology :

Predisposing factors : Smoking, DM, chronicpancreatitis

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Pathology:

Site : 55% involve head of pancreas, 25% Body, 15% tail,

5% at periampullary region

Macroscopic : growth is hard and infiltrating Histology: 90% ductal, 7% acinar cell, 2% cystic, 1%

connective tissue origins.

Spread : lymphatics to peritoneum and regional nodes,

via bloodstream to liver and lung. Metastase oftenpresent at time of diagnosis

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Clinical features

Head of pancreas or periampullare Painless, progressive jaundice with a palpable gallbladder (

Courvoisiers law : a palpable gallbladder in the presence of

jaundice is unlikely to be due to gallstones )

Ocasionally, doudenal obstruction causing vomiting

Body of pancreas

Back pain, anorexia, weight loss, steatorrhoea

New aching back pain and vague symptoms may be only presenting

features

Tail of pancreas

Often presents with metastases, malignant acites, unexplained

anaemia

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Invest igat ions

Ultrasound: may see mass in head of pancreas anddistended biliary tree, facilitates needle biopsy

CT: demonstrates tumour mass, facilitates biopsy,

assesses involvement of surrounding structures and local

lymph node spread

ERCP: very accurate in making diagnosis; obtain

specimen or shed cells for cytology and stent may be

placed to relieve jaundice

Barium meal: widening of the duodenal loop with medial

filling defect

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TMN Staging of Exocrine Pancreatic Cancer

Primary tumor (T)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor limited to the pancreas, 2 cm or less in greatest dimensionT2 Tumor limited to the pancreas, more than 2 cm I greatest dimension

T3 Tumor extends beyond the pancreas but without involvement of the

celiac axis or the superior mesenteric artery

T4 Tumor involves the celiac axis or the superior mesenteric artery

(unresectable primary tumor)

Regional lymph nodes (N)NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Regional lymph node metastasis

Distant metastasis (M)

MX Distant metastasis cannot be assessed

M0 No distant metastasisM1 Distant metastasis

Source: Reprinted with permission from the American Joint Committee on

Cancer (AJCC), Chicago, Illinois. The original source for this material is the

AJCC Cancer Staging Manual, Sixth Edition (2002)

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MANAGEMENTAn algorithm showing how treatment should be managed

for carcinoma of the head of the pancreas.The options depend on several factors, including

resectability, the presence of metastasis, and

whether or not the tumor can be visualized.

Pal l iat ion treatment

Pancreatic adenocarcinoma is usually incurable at

time of diagnosis

Jaundice can be relieved by placing a stent through the

tumour either transhepatically or via ERCPDuodenal obstruction may be relieved by

gastrojejunostomy by pass

Pain may be helped with a coeliac axis block

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OBSTRUCTIVE JAUNDICE

ABDOMINAL ULTRASOUND

CT SCAN

TUMOR VISUALIZED TUMOR NOTVISUALIZED

NON OPERABLE OPERABLE ENDOSCOPIC

ULTRASOUND

FNAB ERCP

PALLIATIVE THERAPY BIOPSI

STAGING LAPAROSCOPY

RESECTABLE NON-RESECTABLE

PANCREATICODUODENECTOMYBILIOENTERICGASTROJEJUNAL BYPASS

Algorithm for management of carcinoma of the head of the pancreas.

Abbreviat ions: CT, computed tomography; FNA, fine needle aspiration; ERCP, endoscopicretrograde cholangiopancreatography.

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Fig. Palliative bypass of the

bile duct and stomach in a

patient with a non-resectable

pancreatic cancer.

(A) Choledochojejunostomy, (B)

gastroenterostomy,

(C) entero-enterosotomy

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Curative treatment

Rarely, surgical (Whipples procedure) resection of small

tumours of the head of the pancreas is curative if lymph

nodes are not involved

Prognosis

90% of the patients with pancreatic adenocarcinoma

are dead within 12 month diagnosis.

Important to obtained histology from tomours around the

head of the pancreas as the prognosis of non-pancreatic

periampullary cancer (distal CBD tumours, ampullarytomours, duodenal tumours) is considerably better (50% 5-

years survival rate) following resection

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Fig.Pancreaticoduode

nectomy, which

consists of partial

gastrectomy, partialpancreatectomy, and

excision of the distal

bile duct and all of the

duodenum (Whipplesprocedure) resection

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RECONSTRUCTION OF P NCRE TICODUODENECTOMI

Gastroenterostomy

Choledochojejunostomy

Pancreaticojejunostomy

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CHEMOTHERAPY AND RADIOTHERAPY

Palliative radiotherapy and chemotherapy with 5 Fluorouracil

or gemcitabine alone can prolong Overall Survival

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