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Pancreatic cancer

Pancreatic cancer

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Pancreatic cancer

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

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

  3. INTRODUCTION • 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 • Perineural invasion • Lymphatic spread • Extralymphatic involvement are the liver and peritoneum.

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

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

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

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

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

  9. CT

  10. CT

  11. CT

  12. MRCP

  13. MRCP

  14. Patient 1

  15. Patient 1

  16. Patient 1

  17. Patient 2

  18. Patient 2

  19. Patient 2

  20. Patient 2

  21. Endoscopy • ERCP • Cytology in Pancreatic juice • Tumor marker • Gene detection

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

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

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

  25. P 656

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

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

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

  29. choledochojejunostomy gastrojejunostomy

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

  31. Chemotherapy

  32. Gene Therapy

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

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

  35. Insulinoma

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

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

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

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

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