Pancreatic Cancer: Clinical Manifestations, Diagnosis, and Treatment

Pancreatic Cancer: Clinical Manifestations, Diagnosis, and Treatment

Pancreatic cancer is a dangerous cancer, often detected late, and has a high mortality rate.

1. Types of Cancer Around the Ampulla of Vater:

• Pancreatic head cancer (40-60%): The most common type of cancer around the Ampulla of Vater.

• Ampullary carcinoma (10-20%): Cancer arising from the Ampulla of Vater.

• Distal common bile duct cancer (10%): Cancer arising from the distal part of the common bile duct.

• Duodenal cancer near the Ampulla (5-10%): Cancer arising from the duodenal portion near the Ampulla of Vater.

2. General Symptoms of Cancers Around the Ampulla of Vater:

• Jaundice: Due to bile duct obstruction.

• Bile duct obstruction: Causes indigestion, abdominal pain, and nausea.

• Painless: Initially, patients may not feel pain.

• No fever: Patients usually do not have a fever.

• Differentiable on imaging: Cancers around the Ampulla of Vater can be detected by imaging techniques like ultrasound, CT scan, and MRI.

• Enlarged gallbladder: Due to bile duct obstruction, the gallbladder can enlarge.

3. General Information About Pancreatic Cancer:

• Pancreatic cancer is the fourth leading cause of death in the United States.

• The incidence of the disease increases with age: The disease is common in people over 60 years old.

• The most common type of pancreatic cancer is pancreatic ductal carcinoma: This accounts for approximately 90% of cases.

4. Pancreaticoduodenectomy:

• Criterion for surgery: When the tumor has not invaded the superior mesenteric artery.

• Arterial system of the pancreas: Includes the common hepatic artery, anterior gastroduodenal artery, posterior superior pancreatoduodenal artery, superior mesenteric artery supplying the anterior and posterior inferior pancreatoduodenal arteries.

5. Epidemiology:

• Males are more likely to be affected than females.

• Over 80% of patients are over 60 years old, only 2% are under 40.

6. Causes:

• Chronic pancreatitis: Is the most important risk factor.

• Smoking: Smoking increases the risk of developing the disease.

• Diabetes: People with diabetes have a higher risk of developing the disease.

• Gene mutations: Gene mutations like familial chronic pancreatitis, familial polyposis coli, familial melanoma, BRCA2 breast, and ovarian genetic mutations can increase the risk of developing the disease.

7. Common Cancer Locations:

• Head of the pancreas: The most common location.

• Uncinate process: Also a common location.

8. Clinical Manifestations:

• Late stage: The disease is usually detected at a late stage because the cancer must be large and compress the common bile duct to cause jaundice.

• Tumor size often larger than 3 cm: When diagnosed.

• Lymph nodes and metastasis: Patients often have lymph nodes and metastasis when diagnosed.

9. Gene Mutations Increasing the Risk of Pancreatic Cancer:

• PRSS1 gene mutation: Increases the risk of developing the disease by 70%.

• 4q32-34 gene mutation: Increases the risk of developing the disease by 56%.

10. Physical Symptoms of Cancer Around the Ampulla of Vater:

• Jaundice: Painless, no infection.

• Scratch marks: Due to itchy skin.

• Enlarged gallbladder: Can be palpated.

• Jaundice + Enlarged gallbladder: Courvoisier’s sign, characteristic of cancer around the Ampulla of Vater.

• Left supraclavicular lymph node: Can be palpated.

• Rarely palpable upper abdominal mass: Cancer usually lies deep in the abdomen.

11. Types of Cancer Around the Ampulla of Vater Causing Early Jaundice:

• Ampullary carcinoma: Causes early bile duct obstruction and early jaundice.

• Distal common bile duct cancer: Can also cause early jaundice.

12. Symptoms of Late-Stage Pancreatic Cancer:

• Liver metastases: Appear in the liver.

• Left supraclavicular node (Virchow’s node): Appears in the left supraclavicular node.

• Umbilical metastases (Sister Mary Joseph’s node): Appears in the umbilicus.

• Douglas pouch mass (Blumer’s shelf): Appears in the Douglas pouch.

13. Tumor Status at Diagnosis:

• In approximately 80% of cases, the tumor is larger than 3 cm, with lymph nodes and metastasis present at diagnosis.

14. Imaging Diagnosis:

• CT scan: Supports the diagnosis of cancer of the body and tail of the pancreas.

• Ultrasound: Can help detect the tumor.

• Endoscopic retrograde cholangiopancreatography (ERCP): Can detect Ampullary carcinoma and duodenal D2 cancer.

15. Metastasis:

• Cancer of the body and tail of the pancreas: Often metastasizes to the celiac artery.

16. Comparison of Symptoms of Pancreatic Head Cancer and Cancer of the Body and Tail:

• Weight loss: Cancer of the body and tail often leads to more weight loss because it is detected later.

• Jaundice: Pancreatic head cancer often causes jaundice due to compression of the common bile duct.

• Pain: Cancer of the body and tail often causes pain at a late stage and after peritoneal metastasis.

• Dark urine, pale stool, itching: Often seen in pancreatic head cancer.

17. Biochemical Tests:

• Bile duct obstruction: Increased bilirubin, alkaline phosphatase, transaminases, prothrombin time.

• Markers: CEA, CA 19-9.

• K-ras gene: Can detect early cancer in duodenal fluid, pancreatic fluid, and stool.

18. CA 19.9 Marker:

• Elevated in 75% of cases of cancer around the Ampulla of Vater.

• Has high sensitivity and specificity (approximately 86%).

• If significantly elevated, cancer may not be resectable.

• Not used for screening because it is also elevated in benign diseases.

• Can be used to monitor treatment and prognosis.

19. CA 19.9 and CEA:

• CA 19.9 is more sensitive and specific than CEA in the diagnosis of cancer around the Ampulla of Vater.

20. Pancreatic Cancer Imaging on CT:

• Without contrast: The image has the same density as pancreatic parenchyma, unless necrosis or cyst formation is present.

• With contrast: The tumor is heterogeneous, with decreased density compared to pancreatic tissue.

• Secondary findings: Dilation of the common bile duct, dilation of the pancreatic duct.

21. “Double duct sign”:

• Dilation of the common bile duct and pancreatic duct due to pancreatic cancer.

22. Metastasis:

• About 80% of patients have lymph node or liver metastasis at diagnosis.

23. Resectable Stage:

• Stage 0 – IIB.

24. Staging of Pancreatic Head Cancer:

• Stage 0: Cancer confined to the mucosal layer.

• Stage I: Cancer invading the submucosal layer.

• Stage II: Cancer invading surrounding tissues.

• Stage IIA: Cancer invading surrounding tissues but not metastasizing to lymph nodes.

• Stage IIB: Cancer invading surrounding tissues and metastasizing to lymph nodes.

• Stage III: Cancer invading blood vessels, nerves, or distant metastasis.

• Stage IV: Cancer metastasizing to distant organs.

25. Survival Time:

• Stage III: Approximately 8-12 months.

• Stage IV: Approximately 3-6 months.

• If pancreaticoduodenectomy is performed: Survival time may be extended.

26. Summary of Pancreatic Head Cancer Diagnosis:

• Symptoms: Jaundice, painless, no fever, weight loss, itching, enlarged gallbladder.

• Tests: Direct bilirubin, alkaline phosphatase, CA 19-9.

• Imaging: CT scan, ultrasound, ERCP.

27. Treatment of Cancer Around the Ampulla of Vater:

• Curative: Pancreaticoduodenectomy (Whipple procedure).

• Palliative: Stenting of the common bile duct, arterial-digestive anastomosis, gastrojejunostomy.

28. Pancreaticoduodenectomy (Whipple Procedure):

• Indications: Approximately 70% of pancreatic head cancer cases.

• Contraindications: Stage III, IV with invasion and metastasis.

• Procedure: Classic pancreaticoduodenectomy (pyloric excision) or pancreaticoduodenectomy with preservation of the pylorus.

• Prognosis: Presence of lymph nodes near the pancreatic head, along the superior mesenteric artery has a worse prognosis even after lymph node dissection.

29. Which Cancers Around the Ampulla of Vater Can Be Resected:

• Only about 15-20% of pancreatic head cancer cases can be resected.

• Ampullary carcinoma, distal common bile duct cancer, and duodenal D2 cancer have a higher resection rate.

30. Parts to Be Resected in Whipple Procedure:

• Gallbladder: Gallbladder excision.

• Common bile duct: Transverse section of the common bile duct.

• Stomach: Stomach excision or transverse section of the duodenum D1.

• Pancreatic neck: Transverse section of the pancreatic neck and separation of the uncinate process from the superior mesenteric artery.

• Duodenum: Excision of the head of the duodenum.

31. Parts to Be Anastomoses in Whipple Procedure:

• Pancreatic remnant – jejunum: Anastomosis of the pancreatic remnant with the jejunum or pancreatic remnant – stomach.

• Common bile duct – jejunum: Anastomosis of the common bile duct with the jejunum.

• Gastrojejunostomy: Anastomosis of the stomach with the small intestine.

32. Technique for Pancreatic-Jejunal Anastomosis:

• Wirsung duct – jejunal anastomosis: Anastomosis of the Wirsung duct (pancreatic duct) with the jejunum because the Wirsung duct is capable of dilation.

• Pancreatic remnant buried over the anastomosis: Burying the pancreatic remnant that has been anastomosed with the jejunum.

33. Post-Bypass Anastomosis:

• Similar to Roux-en-Y anastomosis.

• Distance from the common bile duct to the pancreatic remnant-jejunal anastomosis: 30-40 cm.

34. Image of Duodenojejunal or Duodenogastric Anastomosis:

• A. Pancreas – jejunum, CBD – jejunum, gastrojejunostomy.

• B. Pancreas – jejunum (end-to-end), CBD – jejunum, gastrojejunostomy.

• C. Pancreas – jejunum (end-to-side), CBD – jejunum, gastrojejunostomy.

35. Complications of Pancreaticoduodenectomy:

• Approximately 40% of patients experience complications.

• Two common complications: Pancreaticojejunal fistula, delayed gastric emptying, abdominal abscess.

• Endocrine pancreatic complications are rare.

36. Complications of Pancreaticojejunal Fistula:

• Approximately 15-20% of patients.

• Can heal after a few weeks or require reoperation.

37. Complications of Delayed Gastric Emptying:

• Common in operations preserving the pylorus.

• Approximately 15-40% of patients.

• Treatment for several weeks.

38. Prognosis of Whipple Procedure:

• 5-year survival rate: 10-20%.

• Prognosis depends on resection margin: No cancer cells (26%), cancer cells (8%).

• Prognosis depends on tumor size and lymph nodes: Lymph nodes present (14%), lymph nodes absent (36%).

39. Palliative Treatment Methods:

• Arterial decompression: ERCP metal stent placement, percutaneous transhepatic biliary drainage (PTBD).

• Gastrojejunostomy: Anastomosis of the stomach with the small intestine.

• Pain relief: Celiac ganglion block.

40. Arterial Decompression Treatment:

• ERCP metal stent placement: If stent placement is not possible, perform PTBD.

• Placement of stent over duodenal stenosis: If stent placement is not possible, perform gastrojejunostomy.

• Cholecystojejunostomy: When the tumor is distant, perform choledochojejunostomy according to Roux-en-Y.

41. Gastrojejunostomy Treatment:

• Approximately 20-25% of patients experience duodenal obstruction.

• If there is no metastasis, patients may live an additional 8-12 months.

42. Pain Relief Treatment:

• Celiac ganglion block: Helps to relieve pain.

43. Method for Roux-en-Y Choledochojejunostomy:

• Jejunal resection: Resection of a jejunal segment.

• Common bile duct – jejunal anastomosis: Anastomosis of the common bile duct with the jejunum.

• Jejunal-jejunal anastomosis: Anastomosis of the two ends of the resected jejunum.

• Loop from common bile duct – jejunum to jejunal-jejunal anastomosis: 40-60 cm long to prevent reflux.

44. Method for Roux-en-Y Hepaticojejunostomy:

• Stent placement: Helps reduce leakage at the anastomosis.

45. Pre-chemotherapy Biopsy:

• Biopsy through CT-guided needle, abdominal ultrasound, endoscopic ultrasound: Determine the type of cancer cells.

46. Chemoradiation:

• Supplement after pancreaticoduodenectomy: Increases 2-year survival (from 18% to 43%).

• Non-resectable: Extends life expectancy.

• Adjuvant chemotherapy: Better than radiotherapy and chemoradiation.

47. End-of-Article Questions:

• Would you like to learn more about advanced treatment methods for pancreatic cancer?

• Would you like to learn about organizations that support patients with pancreatic cancer?

• Would you like to learn about research currently being conducted on pancreatic cancer?