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Elective Course in
Oncology for Medical
Students
Pancreatic Cancer
Case Presentation & Review
in Poznan
Beate Rau
Ductale Pancreatic Carcinoma
Incidence (per year)
Age
Size
Resectability
10 / 100 000
50 - 60 years
2 - 5 cm
5 - 22 % operable
Early lymphatic dissimination
50% of all T1
Pancreatic Cancer
Ductal
Cystadeno carcinoma
ductal adeno carcinoma
Endocrin
endocrine tumors
(Insulinoma, Gastrinoma, VIPom..)
Papilla vateri
adeno carcinoma
3%
92 %
2%
Pancreatic Cancer
Cumulative Survival (%)
100
80
Endocrine Tumors (n=212)
Intraductal carcinoma (n=147)
60
Cystadeno carcinoma (n=327)
40
20
Ductale carcinoma (n=7607)
0
0
20
40
60
Monate
80
100
120
140
Matsuno S, Int JCO, 2000
Prognoses
Stage UICC 2002
I
II
III
IVA
IVB
pT1-2
pT3
pT1-3
pT4
alle pT
N= 4008 patients
N0
N0
N1
Nx
Nx
M0
M0
M0
M0
M1
Diagnosed
5 Yr SR
4%
8%
15 %
24 %
50 %
20 - 40%
10 - 25%
10 - 15%
0-?
0
Matsuno S, Int JCO, 2000
Current standards in colorectal surgery
• Staging
• Surgery
• Multimodal Treatment
Symptoms
Icterus
Abdominal pain
Loss of weight
Acholic faeces
Back pain
Pressure pain
Diabetes mellitus
Head
Corpus
65 %
55 %
45 %
40 %
30 %
30 %
5%
selten
80 %
60 %
selten
55 %
20 %
38 %
Localisation
head
60 %
corpus
15 %
tail
diffuse
5%
20 %
5%
15%
60%
Endoscopic retrograde
Cholangiopancreaticography (ERCP)
Double duct sign
EUS
Head
Corpus
< 2 cm
> 2 cm
S3-Guidelines Pancreatic Cancer 2007
Staging in pancreatic Cancer (Level B)
• TN-Category:
-
Sonography
endosonography
multisclice CT
MRI combined with MRCP
Response
RECIST criteria
Staging Accuracy
Tool
Accuracy
Vascular Infiltr.
 EUS
 CT
 MRI
76%
83%
74%
M1
 EUS
 CT
 MRI
85%
88%
83%
Soriano-A, Am J Gastroenterol 2004
Dissiminated Disease
•
•
•
•
•
Pleura
Lung
Liver
Local
Peritoneum
8%
8%
49 %
26 %
30 %
Hoffman J, JCO 16:317 (1998)
Current standards in pancreatic surgery
• Staging
• Surgery
• Multimodal Treatment
Surgery
Prognoses
Quality of Life
Morbidity
Mortality
Not Resectable
• Infiltration of coeliac trunc
• Superior mesenteric artery
• Infiltration of the
mesenteric route
• Distant metastases
Surgery
Kausch-Whipple OP
 First time in 1909 Walter Kausch in Berlin
Surgery
Pylorus-preserving Pancreaticoduodenectomy
(PPPD) Traverso-LW, Surg Gynecol Obstet 1978
Pancreatic resection including vessels
• N=623 patients
• Portal vein
64 (10 %)
• Mesenteric artery
18 ( 3 %)
Settmacher-U, Chirurg, 2004
Prognoses
100
Survivalrate [%]
R0-Resection (n=100)
80
R1 + R2-Resection (n=62)
60
Bypass (n=139)
40
20
0
10
20
30
40
months
50
60
Trede et al. Ann. Surg. (1992)
Prognoses
Exocrine PC
Kurative :
Palliative :
Neuroendorcine PC
Median survival
5 Yr SR
18 months
6 months
10 - 25 %
0%
40 - 60 %
Palliative treatment
• Icterus
- Stent, PTCD
• Gastric outlet obstruction
- GEA, Jejunal sonde
• Pain
- Obliteration of solaris plexus
Endoscopic Stenting vs. surgical Bypass
Survivalrate [%]
100
80
Stent
60
40
20
Surgery
0
0
10
Months
20
Coeliacus Plexus Obliteration
• Intraoperativ or percutan
• 30-40 ml Phenol or Ethanol
• success rate 50% for 4 months
Current standards in colorectal surgery
• Staging
• Surgery
• Multimodal Treatment
Adjuvant treatment with Gemcitabin
R0-resection
R1-resection
Oettle H, JAMA297:267-277 (2007)
Adjuvant Chemradiotherapy
Neoptolemos J, NEJM 350:1200 (2004)
Neoadjuvant Chemoradiotherapy
neoadjuvant RCT (5-Fu/Cp/Sz, 54Gy)
RCT+ Res
n=20
RCT
n=68
Surgery
n=91
p < 0.006
RCT
n=48
Snady, Cancer 89: 314 (2000)
Algorhytm
Preoperative Staging
T1, T2, M0
T3,M0
Resection
and adj CT
Neoadj. RCT
M1
Palliative CT
• Erythema necrolyticum
• glucagonom
Staging
US
EUS
Staging Accuracy
Tool
Accuracy
Locoregional
 EUS
 CT
 MRI
62%
74%
68%
LN-positive
 EUS
 CT
 MRI
65%
62%
61%
Soriano-A, Am J Gastroenterol 2004
Vascular infiltration
Surgery
OP-Situs after resection
Pancreatic tail resection
Ductale pancreatic cancer
Vessel reconstruction