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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?

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?

Bile is required for absorption

Pts with biliary obstruction require vitamin K to maintain hemostasis

Review Question:

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

Review Question:

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

Common hepatic (from the Celiac trunk)

20. Why is knowing the anatomical variation of the hepatic artery important?

When originating from the SMA it courses posterior to the head of the pancreas
In this position it is at risk in a pancreatic resection

21. What is the staging of pancreatic cancer?

Primary Tumor (T)

T0 - no primary tumor
Tis - carcinoma in situ
T1 - tumor invading
T2 - tumor invading
T3 - tumor invading
T4 - local invasion into adjacent structures

Lymph Node (N)

N0 - no regional lymph node metastasis
N1 - metastasis in
N2 - metastasis in

Distant Metastasis (M)

M0 - no distant metastasis
M1 - distant metastasis

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

Two major patterns of spread occur:

into regional lymph nodes
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, od 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)

Removal of:

Gallbladder
Common bile duct
Duodenum
Head of pancreas
Pylorus
Distal stomach

Restoration of GI continuity via:

Pancreaticojejunostomy
Hepaticojejunostomy
gastrojejunostomy

A. Cross hatching indicates portions removed in the Whipple

B. Schematic drawing of the three anastomoses

28. What is the rationale for total pancreatectomy?

Total pancreatectomy was proposed in the 1960’s when overall survival rates from pancreaticoduodectnectomy was low
low survival rates presumed to be due to multicentricity of tumor
now with improved technique mortality from both operations are equivalent
disadvantages now outweigh advantages

advantages:

total pancretectomy allows dissection of more lymph nodes
elimination of pancreaticojejunal anastamosis and its risk of leak

disadvantages:

requires removal of the spleen
exocrine and endocrine dysfunction requiring insulin as well as digestive enzyme supplementation

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?

Oral, transdermal medications

Celiac ganglion blocks with 95% alcohol
- Celiac block can be performed at the time of surgery
- provides pain relief for 4-6 months.

Intraoperative external beam radiation

may provide up to 4 months of pain relief in selected patients

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?

Overall 5 year survival rate for all patients with resected periampullary tumors is approximately 15-25%.

The site of tumor origin has a large impact on survival.

tumors of the duodenum, distal bile duct and ampulla are associated with 40-60% five year survival

carcinomas of the head of the pancreas are associated with a 5-25% five year survival

37. How would you differentiate between obstructive, hemolytic, and hepatocellular forms of jaundice?

Obstructive jaundice:

inc. direct bilirubin

Hemolytic juandice

inc. indirect bilirubin

Hepatocellular

inc. indirect bilirubin

38. Differential diagnosis includes:

choledocholithiasis

neoplasm of the head of the pancreas

neoplasm of the ampulla of vater
neoplasm of the duodenum