Pancreatic cancer
- Gastroepato
- Oncology
- Pancreatic cancer
- Neoplastic obstructive jaundice
- Gastric cancer: macroscopic classification and TNM
- Gastric cancer
- Colon carcinoma
- Colorectal and stomach cancer
- Gastric polyps
- Gastric polyps
notes by dr Claudio Italiano
Signs of pancreatic cancer
Signs include neoplastic jaundice.
A pain during the second
phase of digestion, is not always due to the duodenum ulcer, especially if it is
intense, unbearable and referred to the shoulder. The writer, by his experience,
has had several patients suffering from this severe form of neoplasia, for which
early diagnosis or knowledge of a genetic and family predisposition are the
basis of therapeutic success. In fact, if you are aware of a familiarity in the
development of the tumor, you need to carry out prevention and screen
the family members.
Unfortunately, after a long time, the writer has managed
the diagnostics of a man treated for ulcers and considered suffering from
irritable bowel syndrome that was rather affected by pancreatic cancer.
Let us remember that the cure is always the last act of a diagnostic procedure!
To this gentleman, having performed an ultrasound and on this a TAC abdomen and,
therefore, a nuclear magnetic resonance, a suspicious nodule was found. He then
performed a targeted biopsy, but the tumor had already been extended to the
vessels and the peritoneum. The same was treated in palliation and, the most
beautiful thing to say is that he was concerned about the health of his loved
ones, because until the end he had no knowledge of the pathology that gripped
him.
Epidemiology
The risk of developing pancreatic cancer increases with age, so much so that
before the age of 60 it is rare to find it: just in 15% of cases; 50% develop,
however, between 60 and 80 years; 25% of cases develop over 80 years.
The causes of pancreatic cancer are:
- Hereditary in 10%, that is, if there is familiarity, if the father is ill, the
child will also be able to get sick.
-
In 30% of cases it is always about smoking; smoking is an important cause of
pancreatic neoplasm and more.
-
Benign injuries only in 4% of cases
-
The diet in 20% of cases contributes to the etiopathogenesis.
-
In 36% of cases the reason is unknown.
And when we talk about diet we mean a high consumption of meat, foods rich in
cholesterol, fried foods and sausages with nitrosamines (eg salami and sausages),
while fruits and vegetables seem to reduce the risk. Obesity, weight in general
and lack of physical activity also play a fundamental role; we have seen that
obesity is frequently associated with pancreatic cancer (Michaud et al., Jama,
2001;
A recent meta-analysis of occupational risk to develop cancer (exposure to
environmental carcinogens) was conducted in 92 studies, grouping 23 carcinogens;
it turned out that the following substances are responsible for the development
in the following percentages:
-
CHC solvents1.4%
- Nickel to compounds with nickel 1.9%
- Chromium and chromium compounds 1.4%
- Polycyclic aromatic hydrocarbons 1.5%
- Organochloric insecticides 1.5%
- Silicon powder 1.4%
- Aliphatic and alicyclic hydrocarbons solvents 1.3%
Cystic fibrosis and cancer
Cystic fibrosis plays its role, since cancer is a very rare event in people
with cystic fibrosis. The cancer in these subjects is five times more common
than the general population, but the subjects with cystic fibrosis are less than
40 years old, that is, less than those suffering from pancreatic cancer, so this
reduction in incidence is not significant. Because the age of these subjects
tends to increase over time, cancer could most likely become more common in
these populations.
Genetic mutations and pancreatic cancer
Lal and colleagues studied 102 cases of pancreatic cancer in Ontario. Based on
their family history, 38 of these patients were classified at high risk for a
genetic mutation identified in 5 of them (1-p16; i-Brca1 and 3-Brca2). Four of
these patients associated cancer with this mutation. Known causes of genetic
predispositions are important factors only in a small percentage of pancreatic
tumors. In these subjects, smoking or not is a cause of early development of
cancer; so in one study it was shown that 16 subjects who developed cancer were
smokers; others that were not developed later only 20 years later (Lowenfels et
al., JAMA, 2001). The sense of studying these mutations and these genetic
predispositions consists in the fact that such subjects must be screened.
Malignant tumors are the most frequent tumors of this organ,
representing 2% of all malignant neoplasms and about 10% of those of the
gastrointestinal tract.
The malignant tumor of the pancreas, or carcinoma, is more common in
men than in women (ratio of 1.5: 1) and in recent decades has shown a
significant increase in frequency.
Benign tumors are rare, accounting for 6 to 10% of pancreatic
neoplasms.
The most frequent benign tumors are divided into:
- Serous cystic solid adenomas
- mucinous cystic solid adenomas
- intraductal papilloma
These tumors must be differentiated from the simplest cystic forms that
often appear in patients with previous episodes of pancreatitis (inflammation of
the pancreas).
Extremely important is the early diagnosis of mucinous cystadenoma as it is
considered a possible precursor of the malignant tumor. More often it appears in
the 6th decade of life and is currently the 4th-5th cause of cancer death in
Western countries.
Classification of pancreatic tumors in histological
types
We distinguish:
Ductal adenocarcinoma (75-90% of the cas, the most frequent) The most frequent
localization is the head (65%), while the body (30%) and tail (5%) are rarer.
Mucinous adenocarcinoma
Acinar cell carcinoma
Adenosquamous carcinoma
Anaplastic carcinoma
Carcinoma with castone cells
Endocrine and ductal cell carcinoma mixed
Giant-osteoclastic-like giant cell tumor
Mucinous cystoadenocarcinoma
Papillary intraductal carcinoma
pancreatoblastoma
Pseudopapillary solid cell carcinoma
Symptoms
The symptoms that most often occur in pancreatic cancer are:
-
ache
-
dyspepsia (slow digestion, laborious, nausea, vomiting)
-
slimming
-
neoplastic jaundice (yellowish coloration of the skin, as shown on one side of
our case)
-
ascites in the terminal phases by peritoneal metastasis (neoplastic ascites)
Pain arises due to the infiltration or compression of the nerve plexuses, and is
a "belt" type of pain, that is, it assumes a distribution involving the upper
abdominal quadrants and rearward irradiation to the back, all around the waist
of a person.
Dyspepsia, more common in head cancer, is generally characterized by anorexia,
nausea, vomiting and irregularity of the alve (constipation alternating with
diarrhea).
Weight loss, which is not always present, is related to the dyspeptic symptoms
described above as well as to the malabsorption resulting from the altered
pancreas exocrine function.
Jaundice is one of the most constant and early signs of pancreatic head cancer
(80-90%), while it is much less frequent and late in tumors of the pancreatic
body and tail. It is due to compression and / or invasion of the common bile
duct and is associated with pruritus, hypochloic stools and hyperchromic urine.
The most common presentation of pancreatic tumors is that of a hard nodule that
infiltrates the surrounding tissues without a clear margin being evident. In the
case of cystic forms the presence of apparently and microscopically well
delimited formations containing the liquid and / or mucous material will be
detected.
CT abdominal: pancreatic head tumor, arrows
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Diagnosis
Pancreatic tumors are difficult to diagnose, especially at an early stage as the
symptoms are often extremely blurred and non-specific. Furthermore, the pancreas
is deeply placed in the abdomen and is therefore difficult to investigate by
traditional instrumental methods. Among these we remember:
laboratory tests - CEA and CA tumor markers 19.9
radiological examinations:
- ultrasound - represents the first instrumental survey, easy to use. It allows
to evaluate the biliary tract (verifying the presence of calculations) and any
morphological variations in the structure of the pancreatic gland.
- CT abdomen - this examination allows an adequate assessment of the neoplastic
lesion.
- cholangio RMN - often of integration to the CT investigation. It allows to
evaluate the vascular structures adjacent to the neoplasia and the morphology of
the pancreatic duct of Wirsung.
- ERCP (endoscopic retrograde cholangiopancreatography) - this investigation
through the injection of contrast medium directly into the excretory pathways (biliary
choledochus and pancreatic duct) is extremely reliable and precise.
- Biopsy - progressively abandoned due to the increasing reliability of
instrumental investigations and the risk of dissemination of neoplastic cells
along the passage of the needle.
When to operate?
It is contraindicated if you are:
· Liver metastases, distant peritoneal
· Vascular infiltration with obliteration (mesenteric-portal axis, upper
mesenteric a, hepatic)
· Relatively contraindicated if there is a tangential involvement of the
mesenteric-portal axis and infiltration of the duodenum, pyloric antrum and
colon.
In any case the exeresis must be complete, with tumor-free resection margins (VBP,
isthmus-body, posterior pancreaticoduodenal area, retroperitoneal margin);
lymphectomy extended to the II level lymph nodes; removal of autonomic
extrapancreatic nerve plexuses (capital plexuses, plexus of pancreaticoduodenal
aorta). Surgery is currently the only effective treatment in this condition.
Survival at 5 years does not exceed 6% for pancreatic head cancers if they have
been diagnosed late and treated badly, whereas for Vater's papilla tumors it is
40% (generally the diagnosis is early for immediate appearance of jaundice).
Radical resection depends on the location of the neoplasia, but due to the
greater frequency of neoplasms of the pancreas head the most common intervention
is represented by the duodeno-cephalalo-pancreatectomy, which consists in the
removal of the duodenum with the head of the pancreas, of the terminal bile and
possibly the last portion of the stomach (pylorus). All locoregional lymph nodes
are removed together.
tumors index