Pancreatic Tumours - Exocrine & Endocrine

This topic - Pancreatic Tumors includes both Exocrine & Endocrine Tumorous lesions of Pancreas. Mainly for MBBS - Students, they should be familiar with Ca. Pancreas. This PPT covers the latest treatment strategy of Ca. Pancreas and also includes the 2 important Endocrine Pancreatic Tumors.

1. Prof. U.Murali.
Pancreatic
Tumours

2. 2
Learning Objectives
•Introduction
•Classification – P T
•Ca. Pancreas
•Aetiology
•Clinical Features
•Management
•Types – Endocrine P T
•Insulinoma
•Gastrinoma

3. 3
•Pancreatic cancer is the seventh
leading cause of cancer deaths in men
and women worldwide.
•Nearly 85% of patients present with
unresectable (or) metastatic disease.
•Even among those who undergo
surgery, 5-year survival is around 20%.
•More than 85% of pancreatic cancers
are ductal adenocarcinomas.
•Endocrine tumors of the pancreas are
rare.
Introduction

4. Pancreatic Tumours - Types
Exocrine
•Benign - Rare
•Malignant
-Adenocarcinoma
-Cyst aden.ca.
Endocrine
•Insulinoma
•Gastrinoma
•Glucagonoma
•Vipoma
•Somatostatinoma
Others
•Lymphomas

5. Carcinoma Pancreas

6. Carcinoma Pancreas
Carcinoma pancreas is higher in men.
It is common in African American
males.
80% of pancreatic cancers are
metastatic at the time of first diagnosis.
Mean age is 60-65 years.
Head and neck region | 70%
Ampullary & periampullary region |
Body and tail — 30%

7. C P - Etiology
Demography
•Age
•Male gender
•Black ethnicity
Life style
•Smoking
•Diet rich in Fat
•Obesity
Others
•Family history
•Chronic pancreatitis
•Diabetes
•Cirrhosis
•FAP / HNPCC / PJ S
•Previous cholecystectomy
•Carcinogens -Benzidine

8. Pathology & Spread
Solid – 75%
•Duct.adeno.Ca. –
85% - Common –
Head, neck &
ampulla
•Acinar cell Ca.
•Pancreatoblastoma-
Children
Cystic
•Serous
- Benign
- Older woman
•Mucinous -Common
-MCN –Body/tail
-IPMN –Head
•Dermoidcysts
•Duplication cyst
•Lymp.epith.cyst
Lesions
Spread
•Local spread –
adjacent organs
•Nodal spread
•Distant spread

9. Clinical Features
•H & N = Wt. loss &
Jaundice
•Amp = Int.jaun & Wt.loss
•Cystadenocarcinoma =
pain / mass / no
jaundice [Body + Tail]
•Pain – site - Back
•Painless jaundice
•LOW / LOA
•Pruritus
•Tea coloured urine
•Stools – pale
•Jaundiced
•Tenderness
•GB - palpable
•Liver - palpable
•Mass - palpable
•Metastasis - signs
Presentation Symptoms Signs

10. Compare & Contrast
Sl.no
Features Ca – Head Ca – Periampullary
1. Pain & Wt. loss Early features Late features
2. Jaundice Persistent & progressive Intermittent
3. Palpable GB 30% - palpable 50% - palpable
4. Occult blood Absent Present / Silvery
5. Endoscopy Growth – not visible Growth – visible
6. Prognosis Not good Good

14. Investigations
•CBP / LFT
•U/S - Abdomen
•UGI – Endoscopy
•ERCP – inoperable cases
•CECT – scan / MRI
•EUS – guided biopsy
•T M = CA - 19-9

15. Pre – Op – Preparation
•CBD – Stone
•Ca. CBD
•B D –Stricture
•Chr.pan.titis
•R P –Tumour
•L N –CBD
Hepatic Mets
Perit. Mets
L N – Mets
SMV / PV / HA
Glucose – Oral / I V
Inj. Vit – K – 10 mg I.M.
Antibiotics
Improve Hydration / Nutrition
Flushing – Kidney
Oral neomycin / lactulose
Electrolyte Imbalance –
Correction
Contraindications
D / D

16. Treatment
> 85% = Unsuitable for resection / Only 10-15% - are operable
1-Resectable
2-Border-line - R
3-Locally -
Advanced
4-Metastatic
4 - Categories

18. Treatment
•PPPD – Standard procedure
•Whipple’s Operation
•Total pancreatectomy
•Distal PT & ST – Body & tail
•Down-staging not to done
• Gemcitabine ±
Capecitabine
• m FOLFIRINOX
- 5 FU
- Leucovorin
- Oxaliplatin
- Irinotecan
•Chemo-radiation
Surgical Resection Adjuvant Therapy

19. Palliation
Surgical biliary by - pass – CDJ + GJ
ERCP & Stenting – DS / BS / PTHS
Chemotherapy – N A C T - given
Symptom relief & Q O L =
Enzyme replacement for steatorrhea
Treat diabetes
Control - Pain
Un-Resectable cases

21. Pancreatic Endocrine Tumours

22. Pancreatic Endocrine Tumours
Functions
•Islet – Lang – 1-2%
•1million Islets
•4 main types –cells
-β= insulin
-α= glucagon
-δ= somatostatin
-PP = polypeptide
-G cells
P E T
•5 % - all pan.
tumors
•Asso. with MEN
•Single / Multiple
•Benign / Malignant
•Functional / Non-
functional
•Body & Tail
Tumour
Incidence
%
Malig
%
Insulinoma 70-80 < 10
Gastrinoma 20-25 60-90
Non-Functional tumours 30-50 60-90
Glucagonoma – “4 D” –
Disease / Syndrome
4 50-80
VIP - oma 4 40-70
Somatostatinoma < 5 > 70
Carcinoid < 1 60-90

23. Insulinoma
Insulinomas are the commonest PET.
They have been diagnosed in all age
groups with the highest incidence
found in the 4th – 6th decades.
Women seem to be slightly more
frequently affected.
The aetiology and pathogenesis are
unknown. No risk factors have been
associated with these tumours.
Are associated with MEN-1 syndrome.
90% of insulinomas are of <2 cm in
diameter & considered benign.
This is an insulin-producing tumour of
the pancreas causing the clinical
scenario know as Whipple’s triad:
•Hypoglycaemia after fasting (or)
exercise
•BS < 45 mg% - during the attack
•Symptoms relieved by IV - glucose
exercise
* Plasma glucose levels - <2.8 mmol/L
and
* Relief of symptoms on I V – adm.of
glucose

24. Insulinomas – C / F
Common
•Fasting hypoglycaemia
•Hypoglycaemic
symptoms
CNS
Symptoms
•Diplopia
•Blurred vision
•Confusion
•Amnesia
•Abnormal behavior
•LOC / Coma
Others
•Sweating
•Weakness
•Hunger
•Tremor
•Nausea & anxiety
•Palpitations
•Overweight

25. Insulinoma – D & D / D
Blood sugar estimation - (< 3mmol/L).
Insulin radioimmunoassay: Usually,
insulin, proinsulin, C-peptide levels are
measured to demonstrate the lesion.
EUS / IOUS – detects 90% - lesions
MRI – Localises the tumour.
U/S & CT – scan.
•Hepatic insufficiency
•Drug effects - Ethanol
•Dumping Syndrome
•Enzyme defects
•Pancreas Transplant
•Nesidioblastosis

26. Treatment
•Diazoxide ╧ insulin
secretion – direct action
•Octreotide ↓insulin sec..
•Doxorubicin &
Streptozotocin =
Malignant lesion
•Superficial – Enucleation =
Open / Laparoscopic
•Deep - Body / Tail / Duct =
Distal pancreatectomy
•Malignant – Resection
Medical Surgical

27. Gastrinoma
It arises – G cells of pancreas & 2
nd

most common P E T.
It is more common in males than in
females.
It causes ZES – Type II.
The aetiology and pathogenesis of
sporadic gastrinomas are
unknown.
Most are found in the head of the
pancreas, first and second part of
the duodenum -
Gastrinoma / Passaros Triangle
Gastrinoma causes ulcer of unusual
nature (refractory/ resistant); unusual
recurrence (repeated and multiple);
unusual number (multiple); unusual sites
(2nd/3rd part duodenum/jejunum);
unusual age (young and aged).

28. Gastrinoma – C / F
Over 90% patients with gastrinomas
have peptic ulcer, often multiple (or)
in unusual sites.
Diarrhoea is another common
symptom.
Abdominal pain from either PUD or
GORD remains the most common
symptom, occurring in more than 75%
of patients.
When malignant commonly present
with secondaries in liver (80%)/lymph
nodes/lungs or bones.

29. Gastrinoma – D & D / D
F.Gastrin assay - > 1000 pg/ml. (N - < 100)
UGI – scopy.
U / S - abd, EUS.
MRI / CT – scan – Localises the tumour.
Somatostatin receptor scintigraphy (SRS) is
used to locate the site of tumour. It is the
Gold Standard in the evaluation - PNETs
•Idiopathic PUD
•Idiopathic Diarrhea
•GORD
•Chronic atrophic gastritis
•Retained antrum – after GR

30. Treatment
•PPI & Octreotide = ↓
acid hyper-
secretion
•Streptozotocin +
Doxorubicin & 5 Fu
= Metastatic lesion
•Head – Enucleation + peri-
pancreatic L N - dissection
•Body & Tail – Enucleation or distal
resection +/- Duodenectomy
•Duodenum – Open & palpate /
Enucleation (or) excision of wall of
duodenum
Medical Surgical

31. PNETS - STAGING

32. References

33. To Summarize
 Classify Pancreatic Tumours.
 Aetiology & Pathology of Ca. Pancreas.
 Compare & Contrast – Ca. Head & PA Ca. Pancreas.
 Clinical features & Investigations of Ca. Pancreas.
 Treatment Categories of Ca. Pancreas.
 Classify Pancreatic Endocrine Tumours.
 Discuss – Insulinoma & Gastrinoma.

34. Question Time
 Classify Exocrine & Endocrine Pancreatic Tumours.
 Enumerate 6 clinical presentations of Ca. pancreas.
 Compare & Contrast – Ca. Head & PA Ca. pancreas.
 Pre-operative preparatory methods of OJ patient.
 Enumerate 5 etiological factors of Ca. pancreas.
 Name the adjuvant treatment of Ca. pancreas.
 Identify palliative treatment methods of Ca. pancreas.
 List 5 differences between Insulinoma & Gastrinoma.

35. Whipple’s triad of features classical for the
diagnosis of insulinoma constitutes all the
following, except –
a) Signs & symptoms of hypoglycemia.
b) Serum insulin greater than 6 micro units/dl.
c) Serum glucose less than 2.8 mmol/l.
d) Relief of symptoms on administration of glucose.

36. Most carcinoma of the pancreas
are –
a) Acinar cell carcinomas.
b) Islet cell adenocarcinomas.
c) Duct cell adenocarcinomas.
d) Papillary cystic tumors.

37. The ideal surgical treatment for a 1 cm
insulinoma located in the superficial &
distal part of body of pancreas is –
a) Enucleation.
b) Distal pancreatic resection.
c) Whipple’s operation.
d) Angiographic embolization.

38. Which of the following is not a
contraindication for resection of head of
pancreas? –
a) Liver metastasis.
b) Ascites.
c) Peritoneal seedlings.
d) Involvement of major artery.

39. Which of the following is known as 4 D
disease/syndrome? –
a) Gastrinoma.
b) VIP oma.
c) Somatostatinoma.
d) Glucagonoma.

40. A 60-year-old patient presents with obstructive jaundice.
The ultrasound shows that the gallbladder is distended,
the bile duct is dilated till the terminal end and there is a
mass in the head of the pancreas, indicating cancer. The
most useful investigation to assess resectability is –
a) ERCP.
b) MRCP.
c) CT scan.
d) Doppler ultrasound.

41. Thank you