1. What are the typical symptoms of pancreatic cancer?

• Often asymptomatic in early stages:
• Later symptoms may include:
• Weight loss
• Anorexia
• Epigastric discomfort
• Back pain
• Jaundice (only in cancer of the head of pancreas)

2. What percentage of patients present with pancreatitis as the first symptom of pancreatic cancer?

• 3-14%

3. What are the typical features of pain from pancreatic cancer and what does the pain signify?

• pain exacerbated by recumbancy relieved when sitting up and leaning foreword
• signifies perineural invasion of the tumor- a poor prognostic indicator

4. What would polyuria and polydipsia in this patient signify?

• Diabetes

5. Approximately what percentage of patients present with Diabetes as a sequelae of pancreatic cancer?

• 15%

6. At what age does pancreatic cancer present and is there a female/male predominance?

• Pancreatic cancer presents in the fourth to sixth decade
• Predominance in males

7.What are the risk factors for pancreatic cancer?

• Smoking
• High fat, low fiber diet
• Chronic calcified pancreatitis
• Occupational exposure to petroleum products, benzidine

8. Where is jaundice first seen?

• Sclera

At what serum bilirubin does it first become evident?

• Serum bilirubin >2-2.5

9. What is Virchow’s node?

• Left supraclavicular node

10. What is a Courvoisier gallbladder?

• Dilated gallbladder
• Associated with malignant biliary duct obstruction

11. What percentage of patients have a Courvoisier gallbladder?

• 50% of patients with carcinoma of the head of the pancreas

12. Why should the umbilicus and cul-de-sac be examined carefully?

• Metastatic peritoneal implants can be detected:
• Sister Mary Joseph nodes (umbilicus)
• Blumer’s shelf (cul-de-sac- palpable on rectal exam)

13. What serum diagnostic tests should be performed?

• CBC
• Electrolytes
• Liver function studies
• PT/PTT

14. What radiographic studies can be performed? Are any of these specific for pancreatic cancer?

• Studies that image the pancreas
• Ultrasound
• Endoscopic ultrasound
• CT
• MRI
• Studies that image the biliary tree and pancreatic ducts
• PTC
• ERCP
• Studies of vascular structures of the pancreas
• Celiac and mesenteric angiography

None of these tests are highly specific for pancreatic cancer. CT and ultrasound are the least invasive and very sensitive for lesions >2 cm. However a smaller lesion may not be seen. In this case endscopic ultrasound is a useful procedure.

15. What are the types of non-islet cell pancreatic cancer?

• Adenocarcinoma
• Lymphoma
• Cystadenocarcinoma
• Squamous cell carcinoma
• Acinar cell carcinoma

16. What is the most common type of pancreatic cancer?

• 90% of malignant exocrine tumors are duct cell adenocarcinomas

17. What is the prevalence of pancreatic cancer?

• 5^th leading cause of cancer death
• 28,000 new cases diagnosed un the US each year

18. Why is vitamin K given?

What are the vitamin K-dependent clotting factors?

• II
• VII
• IX
• X
• Protein C
• Protein S

19. What percentage of patients have an anomalous origin of the right hepatic artery and from what vessel?

• 15-20% have a right hepatic originating from the SMA

From what artery does the right hepatic artery originate in the majority of the population?

• Common hepatic (from the Celiac trunk)

21. What is the staging of pancreatic cancer?

22. What is the pattern of spread of pancreatic cancer?

Two major patterns of spread occur:

1. into regional lymph nodes
2. local invasion of contiguous structures

23. Which pancreatic cancers can be resected for "cure"?

• small tumors (<2 cm)
• no local invasion

24. What are the findings at staging that predict unresectability?

• Tumors involving the body or tail
• Invasion of contiguous structures
• Invasion of the bile duct
• Involvement of celiac, hepatic, or superior mesenteric arteries
• Involvement of portal, splenic, or superior mesenteric veins
• Hepatic mets
• Peritoneal seeding
• Gross nodal mets

25. What are the techniques for pancreatic biopsy?

• Open Wedge biopsy
• Core needle biopsy
• Fine needle (CT guided)

26. What are the risks of biopsy?

• Open wedge biopsy have risk of pancreatitis and pancreatic fistula
• Core biopsy also has risk of developing fistula
• Fine needle has lowest complication rate (1-2%)

27. What is the most common resection performed for pancreatic cancer?

• Whipple procedure (pancreatoduodenectomy)
1. Removal of:
1. Gallbladder
2. Common bile duct
3. Duodenum
4. Head of pancreas
5. Pylorus
6. Distal stomach
2. Restoration of GI continuity via:
1. Pancreaticojejunostomy
2. Hepaticojejunostomy
3. gastrojejunostomy

28. What is the rationale for total pancreatectomy?

29. Is there a role for preoperative biliary tract decompression?

• Randomized prospective studies have shown that routine percutaneous transhepatic biliary drainage does not reduce operative mortality and morbidity and may increase hospital stay.

• Biliary drainage is indicated in patients with biliary sepsis secondary to cholangitis or in patients with major nutritional deficiencies because of severe biliary obstruction.

30. What palliative procedures for pancreatic cancer are currently available and what are the advantages and risks of each?

1. Minimally invasive

• percutaneous transhepatic drainage catheter (PTC)
• advantage: constant access to the biliary system
• disadvantage: requires an external catheter.
• endoprothesis
• advantage: endoprotheses drain internally
• disadvantage: subject to obstruction by biliary sludge and require endoscopic surgery for placement and revision.

2. Palliative surgery

• Biliary-enteric bypass with gastrojejunostomy
• Advantage: gastrojejunostomy prevents development of duodenal obstruction
• Disadvantage: an invasive procedure with associated operative risks

31. How common is duodenal obstruction?

• Approximately 6-30% of patients with nonresectable cancer will develop duodenal obstruction.

32. What palliative procedures for pain control are available?

33. What are the current operative morbidity and mortality rates for pancreatoduodenectomy? For total pancreatectomy?

• Perioperative mortality rate from pancreatoduodenectomy is less than 5%.
• Mortality from total pancreatectomy is approximately equivalent, however it caries added morbidity due to exocrine and endocrine dysfunction after resection

34. What are the major complications of pancreatoduodenectomy and total pancreatectomy?

     Complications of pancreatoduodenectomy:

• Anastamotic leak
• Abscess
• Fistula
• Pancreatitis
• infection

    Complications of total pancreatectomy:

• Same complications as above +
• Bleeding
• Hypoglycemia

35. Is there a role for adjuvant chemotherapy and radiation?

• Combination external beam radiation therapy and 5-fu may improve survival following resection
• chemotherapeutic and radiotherapies also used for palliation of unresectable or recurrent disease
• no increase in survival has been found in patients with inresectable disease

36. What are the current survival statistics for pancreatic cancer?

    Obstructive jaundice:

• inc. direct bilirubin

    Hemolytic jaundice:

• inc. indirect bilirubin

    Hepatocellular: