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Pancreatic cancerPancreatic cancer
WU JIAN WU JIAN
Department of hepatobiliary Surgery Department of hepatobiliary Surgery
First Affiliated HospitalFirst Affiliated Hospital
Zhejiang University School of MedicineZhejiang University School of Medicine
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INTRODUCTIONINTRODUCTION Significant increaseSignificant increase Difficult early diagnosis, difficult surgical Difficult early diagnosis, difficult surgical
resection poor prognosisresection poor prognosis 9090 % % patients die within 1 year after patients die within 1 year after
diagnosisdiagnosis 5 year survival rate 15 year survival rate 1 % -% - 33 % % (lowest in (lowest in
malignancy)malignancy) Common in pancreatic headCommon in pancreatic head ,, about 2/3about 2/3
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INTRODUCTIONINTRODUCTION DuctalDuctal Adenocarcinoma accounts for about Adenocarcinoma accounts for about 9090 %%
of pancreatic neoplasms,of pancreatic neoplasms, At the time of diagnosis more than 85 per cent of At the time of diagnosis more than 85 per cent of
these tumours have extended beyond the limits of these tumours have extended beyond the limits of the organthe organ Perineural invasion Perineural invasion Lymphatic spreadLymphatic spread Extralymphatic involvement are the liver and Extralymphatic involvement are the liver and
peritoneum.peritoneum.
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Manifestation of Manifestation of Pancreatic CancerPancreatic Cancer Pain or fullness in epigastriumPain or fullness in epigastrium Jaundice, itchyJaundice, itchy
Dark urine, light stoolDark urine, light stool weight loss, fatigueweight loss, fatigue GI symptomGI symptom OthersOthers
Diabetes mellitusDiabetes mellitus An episode of acute pancreatitisAn episode of acute pancreatitis
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Physical Signs Physical Signs JaundiceJaundice Non-tender gallbladderNon-tender gallbladder ( (Courvoisier's signCourvoisier's sign
) ) In advanced disease ( indicative of an unresIn advanced disease ( indicative of an unres
ectable tumour )ectable tumour ) Ascites Ascites Palpable mass.Palpable mass.
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Strong Suspicion of Pancreatic CancerStrong Suspicion of Pancreatic Cancer
Pain in epigastrium or back in recent two yePain in epigastrium or back in recent two ye
arsars
Recent GI symptom, negative GI testRecent GI symptom, negative GI test
Obstructive jaundiceObstructive jaundice
Unexplained weight lossUnexplained weight loss
Unexplained pancreatitisUnexplained pancreatitis
Unexplained diabetes mellitusUnexplained diabetes mellitus
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Serum Tumor MarkerSerum Tumor Marker
CA199, CA50, CEA , CA242, PCAA, PaA, CA199, CA50, CEA , CA242, PCAA, PaA,
SPAN-1 Dupan for markersSPAN-1 Dupan for markers
K-ras geneK-ras gene
Poor sensitivity and specificityPoor sensitivity and specificity
Combined testCombined test
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Image findingsImage findings
UltrasonographyUltrasonography Computerized tomographyComputerized tomography (CT)/spiral CT (CT)/spiral CT Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)
has no advantage over CThas no advantage over CT
Endoscopic ultrasonographyEndoscopic ultrasonography Endoscopic retrograde cholangiopancreatographyEndoscopic retrograde cholangiopancreatography (ERCP) (ERCP)
Magnetic resonance cholangiopancreatography (Magnetic resonance cholangiopancreatography (MRCP)MRCP) Percutaneous transhepatic cholangiographyPercutaneous transhepatic cholangiography (PTC) (PTC) AngiographyAngiography Positron Emission TomographyPositron Emission Tomography(PET)(PET)
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CT
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CT
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CT
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MRCP
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MRCP
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Patient 1Patient 1
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Patient 1Patient 1
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Patient 1Patient 1
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Patient 2Patient 2
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Patient 2Patient 2
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Patient 2Patient 2
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Patient 2Patient 2
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EndoscopyEndoscopy
ERCPERCP
Cytology in Pancreatic juiceCytology in Pancreatic juice
Tumor markerTumor marker
Gene detectionGene detection
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Combination between Endoscope Combination between Endoscope and Ultrasonographyand Ultrasonography
Endoscopic US (EUS) Endoscopic US (EUS)
Intra-duct US (IDUS)Intra-duct US (IDUS)
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TreatmeTreatmentnt Radical resection is the only effective tRadical resection is the only effective t
herapy optionherapy option pancreatoduodenectomypancreatoduodenectomy
Cholecystojejunostomy, choledochojejCholecystojejunostomy, choledochojejunostomyunostomy
GastrojejunostomyGastrojejunostomy ChemotherapyChemotherapy RadiotheraptyRadiotherapty Gene therapyGene therapy ImmnotherapyImmnotherapy
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Radical ResectionRadical Resection
PancreatoduodenectomyPancreatoduodenectomy (( PDPD )) Whipple operationWhipple operation
Child operationChild operation
Total pancreatectomyTotal pancreatectomy
Regional pancreatectomyRegional pancreatectomy
Pylorus-preserving pancreatoduodenectomyPylorus-preserving pancreatoduodenectomy (PPPD) (PPPD)
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P 656
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Operation ChoiceOperation Choice
Regional pancreatectomyRegional pancreatectomy Severe operation traumaSevere operation trauma Result is not confirmedResult is not confirmed Remain to be verifyRemain to be verify
PPPDPPPD Stomach is preservedStomach is preserved LN around pylorus can not be resectedLN around pylorus can not be resected Mainly in ampullary tumorMainly in ampullary tumor
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Common PointCommon Point
Basic operation: PDBasic operation: PD
Standard operation: PD + D2 lymphStandard operation: PD + D2 lymph
adenectomyadenectomy
Cancer invades to vesselCancer invades to vessel
resection of portal vein or SMAresection of portal vein or SMA
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Palliative ProceduresPalliative Procedures Biliary or GI obstruction Biliary or GI obstruction Ameliorate the quality of survivalAmeliorate the quality of survival Not elevate survival rateNot elevate survival rate Operation methodsOperation methods
CholedochojejunostomyCholedochojejunostomy GastrojejunostomyGastrojejunostomy JejunojejunostomyJejunojejunostomy GastrojejunostomyGastrojejunostomy
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choledochojejunostomycholedochojejunostomygastrojejunostomygastrojejunostomy
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Microinvasive SurgeryMicroinvasive Surgery
Relieve pain, reduce hospital time, reRelieve pain, reduce hospital time, reduce hospital charge duce hospital charge
ProcedureProcedure Endoscopic stentingEndoscopic stenting Percutaneous stentPercutaneous stent Gastrojejunostomy under laparoscopyGastrojejunostomy under laparoscopy
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ChemotherapyChemotherapy
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Gene TherapyGene Therapy
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Periampullary Cancer Periampullary Cancer
Lower part of CBD, ampulla, papilaLower part of CBD, ampulla, papila High frequency of intestinal bleeding High frequency of intestinal bleeding
Fluctuation of jaundiceFluctuation of jaundice
ERCP are the mainstays in differentiationERCP are the mainstays in differentiation
Result is much betterResult is much better
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Endocrine tumor in Endocrine tumor in pancreaspancreas
B cellB cell ,, insulininsulin ,, insulinomainsulinoma G cellG cell ,, gastringastrin ,, gastrinomagastrinoma D1 cellD1 cell ,, vasoactive intestinal peptide(VIP) vasoactive intestinal peptide(VIP)
VIPomaVIPoma A cellA cell ,, glucagonglucagon ,, glucagonomaglucagonoma D cellD cell ,, somatostatinsomatostatin , , somatostatinomasomatostatinoma
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InsulinomaInsulinoma
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Most common endocrinal Most common endocrinal tumor in pancreas , 75%tumor in pancreas , 75%
Acute attackAcute attack Long disease development Long disease development
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Typical Whipple Triad
Hypoglycemia symptom after fasting or Hypoglycemia symptom after fasting or
workwork
glucose <2.8mmol/Lglucose <2.8mmol/L
Symptom relieves after administration of Symptom relieves after administration of
glucose by oral or veinglucose by oral or vein
Clinical ManifestationClinical Manifestation
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Sympathetic symptomSympathetic symptom
Pale, sweat, quick HBPale, sweat, quick HB
Psychiatric symptomPsychiatric symptom
Faintness , dullness, comaFaintness , dullness, coma
Degenerative change of brain Degenerative change of brain
Confusion, disorder behavior, low intelligenceConfusion, disorder behavior, low intelligence
Hypoglycemia SymptomHypoglycemia Symptom
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Laboratory test Laboratory test
Fasting blood sugar(FBS)Fasting blood sugar(FBS) Immunoreactive insulin (IRIImmunoreactive insulin (IRI ) ) > 25> 25
U/mlU/ml Oral glucose tolerance test (OGTT)Oral glucose tolerance test (OGTT) Insulin release testInsulin release test (( IRI/GIRI/G )) > 0.3> 0.3
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image finding image finding
BUSBUS CTCT Selective angiography, Selective angiography, Intraoperative ultrasonographyIntraoperative ultrasonography ( ( IOUIOU
SS )) Sensitivity nearly Sensitivity nearly 100100 %%
LaparotomyLaparotomy
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MRI
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CT
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CT
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Treatment of insulinoTreatment of insulinomama
Resection after determined diagnosisResection after determined diagnosis
Glucose surveillance in operationGlucose surveillance in operation
Multiple lociMultiple loci
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GastrinomaGastrinoma Zollinger-Ellison SyndromeZollinger-Ellison Syndrome
Triangle in pylorus, duodenum and pancreTriangle in pylorus, duodenum and pancre
atic headatic head
UlcerUlcer
TreatmentTreatment Resection of tumorResection of tumor
Total gastrectomyTotal gastrectomy
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THANKTHANKSS !!