Pancreatic Cancer
Elizabeth Dehmer
AM Report
5/2/08
In the news….
Epidemiology
• Increasing incidence over the past few
decades in the US
• 4th leading cause of cancer death in US
• Estimated new cases and deaths in 2008:
– Cases 37,680
– Deaths 34,290
Risk Factors
• Smoking
• Advanced age
• Male sex (M:F 1.3:1)
• Chronic pancreatitis
• Diabetes mellitus
• ?Obesity (BMI>30 compared w/ <23)
– total physical activity was inversely associated with
risk among individuals with a BMI of at least 25 kg/m2
• ?Height
Risk Factors
• Family History: 5-10% of pts with
pancreatic ca have a first degree relative
with the disease
• Several case control and cohort studies of
kindreds with familial aggregations
odds ratio of developing pancreatic cancer
ranges from 1.5-5.25
• Patients in these families present at an
earlier age. Smoking contributes to risk.
Risk Factors
Familial Syndromes associated w/ increased
risk:
– familial atypical multiple-mole melanoma
– familial breast cancer (BRCA-2)
– Peutz-Jeghers
– hereditary nonpolyposis colorectal cancer
– hereditary chronic pancreatitis
Clinical Presentation
• Jaundice (50% of patients)
• Weight loss
• Anorexia
• Bloating
• Steatorrhea or diarrhea
• Abdominal pain or back pain or both
Diagnosis
• Abdominal Ultrasound
• CT Abdomen
• Biopsy (Percutaneous or Endoscopic)
• Serum CA 19-9
– Elevated in 80% of pancreatic ca cases
– Low specificity
– Can be a useful gauge of treatment
Staging
Treatment
• Localized: Radical
pancreatic resection +/-
post-op radiation and/or
chemotherapy
(5-FU or gemcitabine)
• Locally Advanced:
chemotherapy +/-
radiation or clinical trial
• Metastatic Disease:
chemotherapy
(gemcitabine)
Treatment
• At the time of diagnosis:
– 15-20% of pts have localized and resectable tumors
– 40-45% have localized tumors that are unresectable
(generally due to vascular invasion)
– 40-45% have distant metastases
• Contraindications to surgical resection:
– Mets to liver, peritoneum, omentum, or any extra-
abdominal site
– Encasement of celiac axis, hepatic artery or SMA
– Involvement of splenoportal confluence
– Involvement of bowel mesentary
– Involvement of SMV or portal vein
Treatment
• Palliative options:
– Palliative surgical biliary bypass,
percutaneous radiologic biliary stent
placement, or endoscopic biliary stent
placement
– Pain control (including analgesics, celiac
block, chemoradiation)
– Treat fat malabsorption with pancreatic
enzymes
Prognosis
• Overall survival rate 4%
• For patients with small cancers (<2cm)
with no extension beyond capsule of
pancreas, complete surgical resection has
a 5 year survival rate of 18-24%
• For patients with advanced cancers,
survival at 5 years is 1%, with most
patients dying within a year
References
• Castillo, Carlos and Ramon Jimenez. Risk factors for
and molecular pathogenesis of pancreatic cancer.
Uptodate.com 2007.
• eMedicine
• MKSAP 14: Hematology and Oncology
• Michaud, et al. Physical Activity, Obesity, Height and the
risk of pancreatic cancer. 2001 JAMA 286(8): 921-929.
• National Cancer Institute
• Ryan, David et al. Case 20-2005. A 58 year-old man with
locally advanced pancreatic cancer. 2005 NEJM
352(26): 2734-2741.