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    Pancreatic Malignancy

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    lovelots1234
    This document summarizes updates on the management of pancreatic malignancy. It discusses risk factors and tumor markers for pancreatic cancer. Imaging studies like CT, MRI, and PET are important for staging. Multidetector CT is the gold standard for non-invasive staging and can determine vascular involvement and distant metastasis. Several studies on adjuvant chemotherapy and chemoradiation after surgery are summarized, showing some benefit to survival. Neoadjuvant chemotherapy may help convert unresectable tumors to resectable, though it also carries risks of disease progression or post-operative complications. The document concludes that while pancreatic cancer remains very challenging to treat, neoadjuvant approaches may improve resectability in some cases.

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    Pancreatic Malignancy

    Uploaded by

    lovelots1234
    31 views22 pages
    This document summarizes updates on the management of pancreatic malignancy. It discusses risk factors and tumor markers for pancreatic cancer. Imaging studies like CT, MRI, and PET are important for staging. Multidetector CT is the gold standard for non-invasive staging and can determine vascular involvement and distant metastasis. Several studies on adjuvant chemotherapy and chemoradiation after surgery are summarized, showing some benefit to survival. Neoadjuvant chemotherapy may help convert unresectable tumors to resectable, though it also carries risks of disease progression or post-operative complications. The document concludes that while pancreatic cancer remains very challenging to treat, neoadjuvant approaches may improve resectability in some cases.

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    gastroenterology

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    This document summarizes updates on the management of pancreatic malignancy. It discusses risk factors and tumor markers for pancreatic cancer. Imaging studies like CT, MRI, and PET are important for staging. Multidetector CT is the gold standard for non-invasive staging and can determine vascular involvement and distant metastasis. Several studies on adjuvant chemotherapy and chemoradiation after surgery are summarized, showing some benefit to survival. Neoadjuvant chemotherapy may help convert unresectable tumors to resectable, though it also carries risks of disease progression or post-operative complications. The document concludes that while pancreatic cancer remains very challenging to treat, neoadjuvant approaches may improve resectability in some cases.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    31 views22 pages

    Pancreatic Malignancy

    Uploaded by

    lovelots1234
    This document summarizes updates on the management of pancreatic malignancy. It discusses risk factors and tumor markers for pancreatic cancer. Imaging studies like CT, MRI, and PET are important for staging. Multidetector CT is the gold standard for non-invasive staging and can determine vascular involvement and distant metastasis. Several studies on adjuvant chemotherapy and chemoradiation after surgery are summarized, showing some benefit to survival. Neoadjuvant chemotherapy may help convert unresectable tumors to resectable, though it also carries risks of disease progression or post-operative complications. The document concludes that while pancreatic cancer remains very challenging to treat, neoadjuvant approaches may improve resectability in some cases.

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    UPDATES ON MANAGEMENT

    OF PANCREATIC
    MALIGNANCY

    PANCREATIC MALIGNANCY
    Malignancy near the bile duct
    tend to cause obstructive jaundice

    Pancreatic lesions in the body or tail


    tend to be manifested as pain or a mass
    effect.

    PANCREATIC MALIGNANCIES

    RISK FACTORS
    ESTABLISHED

    ASSOCIATED

    POSSIBLE

    Tobacco
    Inherited susceptibility
    Chronic pancreatitis
    Type 2 Diabetes
    Obesity
    Physical activity
    Certain pesticides
    High carbohydrates

    PANCREATIC MALIGNANCIES

    TUMOR MARKERS
    Carbohydrate antigen 19-9 (CA 19-9)
    Elevated in upto 75% of the paitents with pancreatic
    adenoca
    50% of tumor <2 cm will have a normal level
    Level appear related to size and extent of the disease
    Also elevated in cholestatic disease and other malignancies
    Sensitive when it goes beyond thousand.

    Carcinoembryonic antigen (CEA)


    May be elevated with any of the periampullary
    adenocarcinoma but more typically with bile duct
    and duodenal adenoca

    K ras mutation
    PANCREATIC MALIGNANCIES

    IMAGING STUDIES
    RUQ ultrasound
    CT
    MRI
    MRCP
    ERCP
    PTC
    PET

    PANCREATIC MALIGNANCIES

    NON-INVASIVE STAGING
    GOLD STANDARD
    Multidetector spiral CT (up to 64 slices)
    (MDRCT)
    Identifies adjacent vascular structures, the superior
    mesenteric artery and celiac axis
    90 % sensitivity and specificity for vascular study
    Determines tissue planes and degree of circumferential
    involvement
    Distant metastasis can be seen
    Peritoneal dessimination , hepatic involvement and
    pulmonary involvement can be determined

    MDRCT combined with Lap US yields better


    results
    PANCREATIC MALIGNANCIES

    UNRESECTABLE TUMORS
    Cases have increased due to:
    Very good CT MDR in picking up the vascular
    disease
    Picking up small volume liver disease
    Picking up extra pancreatic disease
    Peritoneal disease
    Visible disease

    PANCREATIC MALIGNANCIES

    ROLE OF ADJUVANT CHEMOTHERAPY IN


    PANCREATIC MALIGNANCY
    5 year survival rate after resection is
    under 20%
    80% of resectable tumors are systemic,
    hence adjuvant therapy is imperative
    There were already 6 studies about
    adjuvant chemotherapy:

    PANCREATIC MALIGNANCIES

    ADJUVANT THERAPY STUDY #1


    Mortell in 1960
    Surgery + 5 FU + chemoradiation using split
    course of 40 grey and chemo
    Result: increased survival from 11 to 20
    months

    PANCREATIC MALIGNANCIES

    ADJUVANT THERAPY STUDY #2


    URTC pancreatic and periampullary site
    cancer
    use split course of chemoradiotherapy
    Results: 218 patients showed 20% increase in
    survival

    PANCREATIC MALIGNANCIES

    ADJUVANT THERAPY STUDY #3


    Norway Study
    Chemotherapy alone AMF regimen
    Conclusion chemotherapy may postpone
    recurrence but does not improve the survival
    rate

    PANCREATIC MALIGNANCIES

    ADJUVANT THERAPY STUDY #4


    ASPACI trial European Study
    289 patients
    Group I chemotherapy versus non chemo
    Group II chemoradioation versus non chemo-radiation

    256 patients
    Group I chemo vs observation
    Group II chemoradiation vs observation

    Conclusion:
    adjuvant chemoradiation good for resectable tumor
    chemoradiation deleterious to non resectable tumor
    ASPAC 1 chemotherapy is beneficial but can not answer
    the benefit of chemoradiation
    PANCREATIC MALIGNANCIES

    ADJUVANT THERAPY STUDY #5


    KANKA 1 Germany Study
    358 randomized patients
    Adjuvant Gemcitabine versus observation
    Results: showed established improvement in
    disease free interval
    Conclusion:
    chemotherapy beneficial after pancreatectomy
    reaffirm ASPAC1 result which showed benefit of
    chemotherapy

    PANCREATIC MALIGNANCIES

    ADJUVANT THERAPY STUDY #6


    RTOD 97-04 American Study
    518 subjects
    Gemcitarabine versus 5 FU
    Results: Gemcitabine is superior than 5 FU
    with median survival of 20.6 months versus 17
    months of 5 FU

    PANCREATIC MALIGNANCIES

    NEOADJUVANT CHEMOTHERAPY
    (DUKE UNIVERSITY)
    Platform 5 FU based neoadjuvant
    chemotherapy
    Advantages
    Multimodality conversion of large tumor to a resectable
    tumor, thus avoiding morbidity of whipples procedure
    Delivery of chemotherapy in a well oxygenated body
    works better
    Potential to improve the resectability of borderline
    resectable tumor

    Disadvantages:
    Missed opportunity for resection due to disease progression
    Complication of chemotherapy

    Questions of increase in post-op complication


    PANCREATIC MALIGNANCIES

    GOALS FOR RESECTION

    R0 zero resection

    with hitologically

    zero margin

    R1 zero resection but with

    microscopically positive margin

    R2 left some tumor behind


    PANCREATIC MALIGNANCIES

    TWO PATHS IN THERAPY


    All are required to have
    staging CT scan (MDRCT)
    Laparoscopy
    Neoadjuvant
    Approach
    Surgical Approach
    Chemoradiation 5-6 weeks
    Restaging

    3-6 weeks rest

    PANCREATIC MALIGNANCIES

    NEOADJUVANT CHEMOTHERAPY
    (DUKE UNIVERSITY)

    Restaging
    CT is not that reliable compared to preoperative staging

    Shrinkage is not a good sign of tumor


    containment
    tumor shrinkage Explore Laparotomy
    Increase in the size Confirmatory FNA
    Palliative Therapy

    PANCREATIC MALIGNANCIES

    NEOADJUVANT THERAPY RESEARCH


    (DUKE UNIVERSITY)

    Results:
    Potentially resectable tumors
    3 deaths from the complication of biliary
    stent occlusion
    20% metastatic disease at the time of
    restaging
    60% get resected with:
    72 % negative nodes
    25 % negative margin
    small percent are complete responders

    PANCREATIC MALIGNANCIES

    NEOADJUVANT THERAPY RESEARCH


    (DUKE UNIVERSITY)

    Potentially Locally Advanced Tumors


    77% - defined morbidity and mortality
    chemoradiation
    20% - become metastic disease
    70-80% are resectable
    70% have negative margin
    No complete responders.

    PANCREATIC MALIGNANCIES

    NEOADJUVANT THERAPY RESEARCH


    (DUKE UNIVERSITY)

    Conclusion
    lesser mortality outcomes with neodjuvant
    therapy

    Summary
    50-60% underwent neoadjuvant therapy can be
    resected
    5 FU based Neoadjuvant chemotherapy over a
    5-6 weeks course show 15-20 % locally advanced
    tumor can be resected.

    PANCREATIC MALIGNANCIES

    The challenge to
    treat pancreatic
    cancer is still at
    large.

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