CASE PRESENTATION CC Jaundice HPI 64 yrold man
- Slides: 45
CASE PRESENTATION CC: Jaundice HPI: 64 -yr-old man • • 4 wk h/o anorexia & 15 lb wt loss • 2 days earlier a family members notes jaundice 2 wk h/o - pruritus - dark urine - abdominal pain, midepigastric, dull, constant with radiation to the back
CASE PRESENTATION PMH: DM, type 2 (dx’d 6 yrs ago) PSH: None Meds: glyburide ALL: NKDA SH: Married. No Et. OH or tobacco FH: No malignancies
CASE PRESENTATION Physical Exam Vitals: 120/83 65 12 AF 176 lbs Gen: NAD. Heent: Icteric. OP nl. Neck: Supple. No LAD. Lungs: CTA. Heart: RRR w/o m/r/g. Abd: NABS. Tender MEG. Palpable nontender gallbladder. Ext: No c/c/e.
CASE PRESENTATION Laboratory Data TBili 8. 5 Alk phos 350 AST 78 ALT 90 Albumin Hgb 10. 5 3. 0
Pancreaticobiliary Cancer Rajeev Jain, M. D.
2005 Estimated US Cancer Cases Prostate Men 710, 040 Women 662, 870 32% Breast Lung and bronchus 13% 12% Lung and bronchus Colon and rectum 10% 11% Colon and rectum Urinary bladder 7% 6% Uterine corpus Melanoma of skin 5% 4% Non-Hodgkin lymphoma 4% Kidney 3% Melanoma of skin Leukemia 3% 3% Ovary Oral Cavity 3% 3% Thyroid Pancreas 2% 2% Urinary bladder 2% Pancreas All Other Sites 33% 17% 21% All Other Sites *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2005.
Pancreas • Acinar cells 80% • Ductal cells 10 -15% • Endocrine cells 1 -2%
Pancreatic Cancer • Endocrine - 1 to 2% • Exocrine - > 95% - 85 to 90% ductal origin • Head 60 -70% • Body 5 -10% • Tail 10 -15%
Pancreatic Cancer WHO Classification - Exocrine • Malignant - Ductal adenocarcinoma Osteoclast-like giant cell tumor Serous cystadenocarcinoma Mucinous cystadenocarcinoma Intraductal papillary mucinous carcinoma Acinar cell carcinoma Pancreatoblastoma Solid-pseudopapillary carcinoma Miscellaneous carcinoma
Pancreatic Cancer ACS 2005 Estimates www. cancer. org
Pancreatic Cancer Risk Factors • • Tobacco (RR 1. 5 – 3) • Familial syndromes - Hereditary pancreatitis (AD, cationic trypsinogen gene) • 40% by age 70, up to 75% if paternal - Peutz-Jeghers - Von Hippel-Lindau - Familial atypical multiple-mole melanoma (FAMMM) - Ataxia-telangiectasia - FAP, HNPCC • • • Chronic pancreatitis (RR up to 16) Family history (7 -10%) - 1 st degree relative: RR 3 -5 Diabetes mellitus, type II (RR 2 if DM present > 5 yrs) Others: Obesity, inactivity, diet Michaud DS. Gastrointest Endosc 2002; 56: S 195 -200.
Pancreatic Carcinogenesis • Activation of oncogenes • Inactivation of tumor suppressor genes • Defects in DNA mismatch repair genes
Pancreatic Cancer Presentation • Symptoms & signs - Jaundice, pruritus, acholic stool Abdominal pain Back pain Weight loss, anorexia, nausea & vomiting Curvoisier’s sign: palpable non-tender gallbladder • Acute pancreatitis • New onset diabetes • Pancreatic exocrine insufficiency
Pancreatic Cancer Diagnostic Evaluation • Laboratory - Tumor markers • Radiology - Computed Tomography Scan Magnetic Resonance Imaging (MRI/MRCP) Positron Emission Tomography Percutaneous Transhepatic Cholangiography (PTC) • Endoscopy - Endoscopic Retrograde Cholangiopancreatography (ERCP) - Endoscopic Ultrasound (EUS)
CA 19 -9 Tumor-Associated Antigen • Synthesized by pancreatic and biliary ductal cells • • Lewis A blood group • Upper limit of normal 37 U/ml - Sensitivity 81% - Specificity 90% • • False elevation: cholangitis • Predicts recurrence 5% of population is Lewis A-Band cannot synthesize CA 19 -9 > 1000 predicts unresectability Steinberg W. Am J Gastroenterol 1990; 85: 350 -5.
Pancreatic Cancer CT Scan Pancreas protocol • • • Thin cuts • Second (portal vein) phase - 70 s after IV contrast - Liver metastases - Tumor involvement of portal & mesenteric veins PO/IV contrast First (pancreas) phase - 40 s after IV contrast - Max. enhancement of normal pancreas
Pancreatic Cancer ERCP • Diagnostic - Pancreatic ductal abnormalities - Tissue (brushings) • Sens 18 -60%, Spec 99% • Therapeutic - Biliary drainage • Plastic stent • Metal stent
Pancreatic Cancer ERCP
Endoscopic Ultrasound • Developed to overcome limitations of transabdominal ultrasound - intervening structures - limited resolution • Transducer placed at distal end of side-viewing endoscope
Endoscopic Ultrasound Radial Linear 100° 360°
Pancreatic Mass with Vascular Involvement
Pancreatic Cancer Endoscopic Ultrasound • Tumor staging - more accurate than helical CT in small lesions - and assessing local extent, lymph nodes, & vascular invasion CT better for distant metastases better than angiography ? MRI, MRCP, PET scan • Diagnostic – Fine Needle Aspiration (FNA) - Sensitivity 85% - Specificity 99%
Percutaneous Transhepatic Cholangiography (PTC)
Pancreatic Cancer SUSPICION OF PANCREATIC CANCER Helical CT Scan No tumor Pancreatic head tumor < 2 cm ERCP EUS Pancreatic head tumor > 2 cm Tumor of body or tail of the pancreas Laparoscopy with cytology of washings if + if - Surgical exploration for resection
Pancreaticoduodenectomy
Pancreatic Cancer Palliative Issues • Jaundice - ERCP, PTC, or surgery • Pain - Radiation therapy - Celiac axis neurolysis • Surgical, fluoroscopic- or EUS-guided • Duodenal obstruction - Surgery or metal stent
Endoscopic Stents • Plastic stents: polyethylene - Drainage prior to surgery Up to 11. 5 Fr Life span < 3 months $100 • Metal stents: self-expanding metal stents (SEMS) - Palliative - 10 mm or 30 Fr - Longer patency - Life span > 3 months - $1, 000
ERCP Stent v Surgical Bypass Palliation of Biliary Obstruction in Pancreatic Cancer Flamm CR et al. Gastrointest Endosc 2002; 56(6): S 218 -25.
Plastic v Metal Stent Palliation of Biliary Obstruction in Pancreatic Cancer Levy MJ et al. Clin Gastroenterol Hepatol. 2004 Apr; 2(4): 273 -85.
Duodenal Obstruction
Duodenal Obstruction
Screening for Pancreatic Cancer No guidelines or recommendations Studies in progress – Univ. Washington & Johns Hopkins • Who - High-risk individuals • When - Age 40 yrs or 10 yrs younger than the youngest family member with PC • How - Serology: Genetic and protein markers - Radiology: CT, MRI/MRCP - Endoscopy: EUS, ERCP
Pancreatic Cancer AJCC Staging Primary Tumor (T) T 1 T 2 T 3 T 4 Limited to pancreas, < 2 cm Limited to pancreas, > 2 cm Extension into duodenum, CBD Extension into vessels (not splenic), stomach, spleen, or colon Regional Lymph Nodes (N) N 0 None N 1 Regional nodal metastases Distant Metastases (M) M 0 None M 1 Distant metastases
Pancreatic Cancer AJCC Staging Stage T N M I 1 0 0 2 0 0 3 0 0 1 1 0 2 1 0 3 1 0 IVA 4 any 0 IVB any 1 II III
Biliary Tract Cancer • Gallbladder • Extrahepatic bile duct • Ampulla of Vater
Gallbladder Cancer • • • 2. 5 cases per 100, 000 5 th most common GI cancer 6, 500 deaths/year M: F 1: 3 Risk factors - Gallstones - Porcelain gallbladder - Chronic typhoidal carrier • Presentation - Pain, jaundice - 1 -2% of resected gallbladders • 5 YR Survival: 5% Highest incidences (7 -20/100, 000) • Native Americans (North & South) • Poland • Northern India
Cholangiocarcinoma • 1 case per 100, 000 • Slight M>F • Risk factors - Primary sclerosing - cholangitis (PSC) Choledochal cysts Clonorchis sinensis Hepatolithiasis CBD stones Thorium dioxide (Thorotrast)
Cholangiocarcinoma • Presentation - Obstructive jaundice • Diagnosis - Tumor markers • CA 19 -9 (85%) • CEA (35%) • CA 125 (30 -50%) - ERCP/MRCP - CT scan • Treatment - Surgery • Palliation - Biliary drainage • 5 YR Survival: 5% MRCP of PSC ERCP
Bismuth Classification
Ampullary Cancer • 3 cases per 1 million • Risk factors - FAP - Peutz-Jeghers • Presentation - Jaundice - “Silver stool” • Diagnosis/Staging - EGD, CT, EUS, ERCP • Treatment: Surgery • 5 YR Survival: 25 – 40%
Outcome of Patients after Pancreaticoduodenectomy Operative Mortality Rate (%) Operative Morbidity Rate (%) Median Survival (mos) 5 -Year Survival Rate (%) 3 -15 27 -40 11 -18 6 -26 1 -11 24 -44 22 -33 13 -43 Ampullary Cancer 3 -15 25 -59 38 -49 33 -48 Duodenal Cancer 1 -6 57 -64 86 32 -60 Pancreatic Cancer Biliary Tract Cancer Sarmiento JM, et al. Surg Clin North Am 2001.
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