1. Pancreatic cancer Ayman Hasan Linjawi, MD, FRCSC,
Consultant general and oncology surgery

2. Pancreatic cancer
Rare tumor, round 200 cases per year newly diagnosed patient in Saudi Arabia
Risk factors:
Demographic factors
Old age, male, black
Host factors
Hereditary nonpolyposis colorectal cancer
Familial breast cancer
Peutz-jeghers syndrome
Ataxia-telangiectasia
Familial atypical multiple mole melanoma
Hereditary pancreatitis
Environmental factors
Tobacco

3. Molecular genetics
Tumor suppressor genes: function to control cellular proliferation. When they are mutated, abnormal growth to the cell will happen. Examples, p53, p16, BRACA2…..
Oncogenes: derived from protooncogenes. Activation of these proteins will lead to abnormal cell growth, example I K-ras
Mismatch-repair genes: function to insure the accuracy of DNA replication (maintenance) therefore when mutated abnormal growth will happen. Example, bMSH2, bMLH1.

4. Pathology Tumor of the pancreas are endocrine and exocrine.
The most common neoplasm of the exocrine pancreas (our topic) is adenocarcinomas.
60% arise from the head, 15% body or tail and 20% diffusely involve the whole gland
They are either solid or cystic.

5. Solid epithelial tumors
Ductal adenocarcinomas: 75% of all nonedocrine pancreatic cancer, aggressive tumor metastasis to liver, peritoneum and lung in 80%, the precursor lesions are referred to pancreatic intra epithelial neoplasm (pan IN) or carcinoma in situ.
Adenosquamous carcinomas: rare, contains both glandular and squamous differentiation, more common in patient received chemoradiation therapy.
Acinar cell carcinomas: rare, common in male, larger size, slightly better prognosis.

6. Solid epithelial tumors
Giant cell carcinoma: large size, more than 15cm, poorer prognosis.
Pancreatoblastoma: occur primarily in children age 1 to 15 years.

7. Cystic epithelial tumors
Serous cystic neoplasm: more in female, vary in size, 30% asymptomatic, symptoms include epigastric pain and nausia, located anywhere in pancreas and do no communicate with pancreatic ducts, CT shows honeycomb pattern, rarely malignant (known by metastasis).
Mucinous cystic neoplasm: common in female (9:1 ratio ), do not communicate with pancreatic duct, associated with ovarian type of stroma, 33% associated with invasive carcinoma, 70% arise from body and tail, therefore it is considered premalignant and should be resected.

8. Cystic epithelial tumors
Intraductal papillary mucinous neoplasm: intraductal mucin producing neoplasm, involve the main pancreatic duct or major side branches (communicate with the duct), more common in head and neck and uncinate process, male=female, mucin can be seen oozing from the ampulla of Vater in ERCP, has malignant potential and should be resected.
Solid and cystic papillary neoplasm: primarily in woman (Hamoudi tumor), treated by resection and rarely metastasis.

9. Diagnosis Symptoms and signs:
Virchow node: left supraclavicular adenopathy.
Sister Mary Joseph node: periumblical adenopathy.
Blumers shelf: pelvic drop metastasis
Head of pancreas
Wt loss, jaundice, pain, anorexia, dark urine, lifgt stools, palpable liver and gall bladder, ascites
Body and tail
Wt loss, pain, weakness, abdominal mass, ascites

10. Diagnosis
Lab test: increase lft, bilirubin, INR (decrease hepatic production of vitamin K-dependent clotting factor). Increase CA 19-9.
Radiological test: trans abdominal ultrasound (TAUS) for assessment and biopsy, CT scan for assessment and metastasis, MRCP for assessment of biliary duct, ERCP for assessment of biliary duct and brush biopsy

11. Signs of irresectability
Metastasis to any organ
Involvement of superior mesenteric vein or artery
Portal vein involvement
Celiac axis involvement
Splenic vein involvement

12. Treatment Surgical excision is the only hope for cure
Total or subtotal pancreatectomy for body and tail.
Pancreaticoduodenectomy for head and uncinate process (whipple).
5 year survival rate is only 10% with successful surgery

13. Surgical treatment

14. Treatment
Adjuvant chemotherapy and radiotherapy: did not show significant improvement of DFS and OS.
Neoadjuvant chemotherapy: also failed to show any benefit , used reduce tumor size (down stage the tumor)