1. Pancreatic cancer WU JIAN Department of hepatobiliary Surgery First Affiliated Hospital Zhejiang University School of Medicine

3. INTRODUCTION Significant increase Significant increase Difficult early diagnosis, difficult surgical resection poor prognosis Difficult early diagnosis, difficult surgical resection poor prognosis 90 ％ patients die within 1 year after diagnosis 90 ％ patients die within 1 year after diagnosis 5 year survival rate 1 ％－ 3 ％ (lowest in malignancy) 5 year survival rate 1 ％－ 3 ％ (lowest in malignancy) Common in pancreatic head ， about 2/3 Common in pancreatic head ， about 2/3

4. INTRODUCTION Ductal Adenocarcinoma accounts for about 90 ％ of pancreatic neoplasms, Ductal Adenocarcinoma accounts for about 90 ％ of pancreatic neoplasms, At the time of diagnosis more than 85 per cent of these tumours have extended beyond the limits of the organ At the time of diagnosis more than 85 per cent of these tumours have extended beyond the limits of the organ Perineural invasion Perineural invasion Lymphatic spread Lymphatic spread Extralymphatic involvement are the liver and peritoneum. Extralymphatic involvement are the liver and peritoneum.

5. Manifestation of Pancreatic Cancer Pain or fullness in epigastrium Pain or fullness in epigastrium Jaundice, itchy Jaundice, itchy Dark urine, light stool Dark urine, light stool weight loss, fatigue weight loss, fatigue GI symptom GI symptom Others Others Diabetes mellitus Diabetes mellitus An episode of acute pancreatitis An episode of acute pancreatitis

6. Physical Signs Physical Signs Jaundice Jaundice Non-tender gallbladder ( Courvoisier's sign ) Non-tender gallbladder ( Courvoisier's sign ) In advanced disease ( indicative of an unresectable tumour ) In advanced disease ( indicative of an unresectable tumour ) Ascites Ascites Palpable mass. Palpable mass.

7. Strong Suspicion of Pancreatic Cancer Pain in epigastrium or back in recent two years Pain in epigastrium or back in recent two years Recent GI symptom, negative GI test Recent GI symptom, negative GI test Obstructive jaundice Obstructive jaundice Unexplained weight loss Unexplained weight loss Unexplained pancreatitis Unexplained pancreatitis Unexplained diabetes mellitus Unexplained diabetes mellitus

8. Serum Tumor Marker CA199, CA50, CEA, CA242, PCAA, PaA, SPAN-1 Dupan for markers CA199, CA50, CEA, CA242, PCAA, PaA, SPAN-1 Dupan for markers K-ras gene K-ras gene Poor sensitivity and specificity Poor sensitivity and specificity Combined test Combined test

9. Image findings Ultrasonography Ultrasonography Computerized tomography (CT)/spiral CT Computerized tomography (CT)/spiral CT Magnetic resonance imaging (MRI) Magnetic resonance imaging (MRI) has no advantage over CT has no advantage over CT Endoscopic ultrasonography Endoscopic ultrasonography Endoscopic retrograde cholangiopancreatography (ERCP) Magnetic resonance cholangiopancreatography (MRCP) Endoscopic retrograde cholangiopancreatography (ERCP) Magnetic resonance cholangiopancreatography (MRCP) Percutaneous transhepatic cholangiography (PTC) Percutaneous transhepatic cholangiography (PTC) Angiography Angiography Positron Emission Tomography(PET) Positron Emission Tomography(PET)

12. CT

16. MRCP

18. Patient 1

21. Patient 2

25. Endoscopy ERCP ERCP Cytology in Pancreatic juice Cytology in Pancreatic juice Tumor marker Tumor marker Gene detection Gene detection

27. Combination between Endoscope and Ultrasonography Endoscopic US (EUS) Endoscopic US (EUS) Intra-duct US (IDUS) Intra-duct US (IDUS)

29. Treatment Radical resection is the only effective therapy option Radical resection is the only effective therapy option pancreatoduodenectomy pancreatoduodenectomy Cholecystojejunostomy, choledochojejunostomy Cholecystojejunostomy, choledochojejunostomy Gastrojejunostomy Gastrojejunostomy Chemotherapy Chemotherapy Radiotherapty Radiotherapty Gene therapy Gene therapy Immnotherapy Immnotherapy

30. Radical Resection Pancreatoduodenectomy （ PD ） Pancreatoduodenectomy （ PD ） Whipple operation Whipple operation Child operation Child operation Total pancreatectomy Total pancreatectomy Regional pancreatectomy Regional pancreatectomy Pylorus-preserving pancreatoduodenectomy (PPPD) Pylorus-preserving pancreatoduodenectomy (PPPD)

31. P 656

34. Operation Choice Regional pancreatectomy Regional pancreatectomy Severe operation trauma Severe operation trauma Result is not confirmed Result is not confirmed Remain to be verify Remain to be verify PPPD PPPD Stomach is preserved Stomach is preserved LN around pylorus can not be resected LN around pylorus can not be resected Mainly in ampullary tumor Mainly in ampullary tumor

35. Common Point Basic operation: PD Basic operation: PD Standard operation: PD + D2 lymphadenectomy Standard operation: PD + D2 lymphadenectomy Cancer invades to vessel Cancer invades to vessel resection of portal vein or SMA resection of portal vein or SMA

36. Palliative Procedures Biliary or GI obstruction Biliary or GI obstruction Ameliorate the quality of survival Ameliorate the quality of survival Not elevate survival rate Not elevate survival rate Operation methods Operation methods Choledochojejunostomy Choledochojejunostomy Gastrojejunostomy Gastrojejunostomy Jejunojejunostomy Jejunojejunostomy Gastrojejunostomy Gastrojejunostomy

37. choledochojejunostomygastrojejunostomy

38. Microinvasive Surgery Relieve pain, reduce hospital time, reduce hospital charge Relieve pain, reduce hospital time, reduce hospital charge Procedure Procedure Endoscopic stenting Endoscopic stenting Percutaneous stent Percutaneous stent Gastrojejunostomy under laparoscopy Gastrojejunostomy under laparoscopy

39. Chemotherapy

40. Gene Therapy

41. Periampullary Cancer Lower part of CBD, ampulla, papila Lower part of CBD, ampulla, papila High frequency of intestinal bleeding High frequency of intestinal bleeding Fluctuation of jaundice Fluctuation of jaundice ERCP are the mainstays in differentiation ERCP are the mainstays in differentiation Result is much better Result is much better

42. Endocrine tumor in pancreas B cell ， insulin ， insulinoma B cell ， insulin ， insulinoma G cell ， gastrin ， gastrinoma G cell ， gastrin ， gastrinoma D1 cell ， vasoactive intestinal peptide(VIP) D1 cell ， vasoactive intestinal peptide(VIP) VIPoma VIPoma A cell ， glucagon ， glucagonoma A cell ， glucagon ， glucagonoma D cell ， somatostatin ， somatostatinoma D cell ， somatostatin ， somatostatinoma

43. Insulinoma

44. Most common endocrinal tumor in pancreas, 75% Most common endocrinal tumor in pancreas, 75% Acute attack Acute attack Long disease development Long disease development

45. Typical Whipple Triad Hypoglycemia symptom after fasting or work Hypoglycemia symptom after fasting or work glucose <2.8mmol/L glucose <2.8mmol/L Symptom relieves after administration of glucose by oral or vein Symptom relieves after administration of glucose by oral or vein Clinical Manifestation

46. Sympathetic symptom Sympathetic symptom Pale, sweat, quick HB Pale, sweat, quick HB Psychiatric symptom Psychiatric symptom Faintness, dullness, coma Faintness, dullness, coma Degenerative change of brain Degenerative change of brain Confusion, disorder behavior, low intelligence Confusion, disorder behavior, low intelligence Hypoglycemia Symptom

47. Laboratory test Fasting blood sugar(FBS) Fasting blood sugar(FBS) Immunoreactive insulin (IRI ） > 25  U/ml Immunoreactive insulin (IRI ） > 25  U/ml Oral glucose tolerance test (OGTT) Oral glucose tolerance test (OGTT) Insulin release test （ IRI/G ） > 0.3 Insulin release test （ IRI/G ） > 0.3

48. image finding image finding BUS BUS CT CT Selective angiography, Selective angiography, Intraoperative ultrasonography （ IOUS ） Intraoperative ultrasonography （ IOUS ） Sensitivity nearly 100 ％ Sensitivity nearly 100 ％ Laparotomy Laparotomy

51. MRI

52. CT

54. Treatment of insulinoma Resection after determined diagnosis Resection after determined diagnosis Glucose surveillance in operation Glucose surveillance in operation Multiple loci Multiple loci

57. Gastrinoma Zollinger-Ellison Syndrome Zollinger-Ellison Syndrome Triangle in pylorus, duodenum and pancreatic head Triangle in pylorus, duodenum and pancreatic head Ulcer Ulcer Treatment Treatment Resection of tumor Resection of tumor Total gastrectomy Total gastrectomy

58. THANKS ！