1. 62 years old man Main complaint: Back pain at night but not during the day Loss of appettite Weight loss

2. What would you suggest in order to investigate the patient’s complaints? Blood examinations ? Imaging? Physical examination

3. What are the risk factors for pancreatic cancer ? Can pancreatic cancer be familial?

5. Pancreatic Cancer – Anatomy

8. FNA - adenocarcinoma Which tumor marker will be elevated ? Are there other histologic types of pancreatic malignancies?

9. What are the most common complaints of patients with pancreatic cancer?

10. What are the most common complaints of patients with pancreatic cancer? What are the most common physical findings in patients with pancreatic cancer? Jaundice Abdominal pain Back pain - esp. at night Weight loss Loss of appetite “New diabetes mellitus” “No symptoms” for a long period

11. What is considered resectable pancreatic cancer?

12. Pancreatic cancer - Presentation Extent of disease at diagnosis: –Resectable 20% –Locally advanced unresectable 40% –Metastatic 40%

13. Pancreatic Cancer - Prognosis Median survival –Metastatic disease- 3-6 months –Locally advanced, unresectable  8-12 months

14. The lesion in our patient is resectable...

15. Pancreatic Cancer – Surgery Theoretically - the only curative treatment Only 15-20% undergo pancreatectomy Principles: –Laparatomy should be therapeutic, NOT diagnostic –Resectability should be determined preoperatively –Palliative laparotomy should be avoided when possible

17. Pathologic report Moderately differentiated adenocarcinoma of the pancreatic head Tumor size - 2.2 cm Invasion of duodenal wall Surgical margins free of disease No vascular invasion 14 regional lymph nodes - free of tumor

18. What is the staging of pancreatic cancer in our patient ?

20. T3N0M0

22. What is the 5 years survival of our patient?

24. Is surgery enough ? Should adjuvant therapy be added? Does adjuvant therapy has any value after surgery for pancreatic cancer? What type of surgery? What is the name of the operation?

27. Pancreatic Cancer - Adjuvant Chemo + RT 12.6 m 54 17 m 60EORTC 11 m 119 19 m 333Sohn 11 m 22 20 m 21Kalser 13.5 5319.5 m 120Yeo et al n Median survival n Surgery S+RT+5FUStudy Median survival

28. Pancreatic Cancer- Adjuvant Chemo + RT – Median Survival in Months

29. After 2 years our patient develops ascites and liver metastases. What is the best approach now? Will chemotherapy improve the quality of the remaining life of this patient? Will chemotherapy prolong life? Which chemotherapy is recommended?

31. Pancreatic Cancer- Conclusions Survival: Median (m) 5-y (%) Metastatic 3- 6 0 Locally advanced 6-12 0 Surgery 12 5-15 Surgery + Chemo 18-20 10-20