Chapter 089. Pancreatic Cancer (Part 3)

Carcinoma of the pancreas. A. Sonogram showing pancreatic carcinoma (P), dilated intrahepatic bile ducts (d), dilated portal vein (pv), and inferior vena cava (IVC). B. Computed tomography scan showing pancreatic carcinoma (dark arrows). C. Endoscopic retrograde showing abrupt c utoff of the duct of Wirsung (arrow). D. Magnetic resonance cholangiopancreatography showing obstruction (Obs) in the pancreatic duct (PD). The gallbladder (GB), hepatic duct (HD), and common bile duct (CBD) are labeled.Tissue Diagnosis and Cytology Patients with disease that is potentially curable by surgery, and in whom a highly suspicious lesion is seen on imaging, are often taken directly to...
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Chapter 089. Pancreatic Cancer (Part 3) Chapter 089. Pancreatic Cancer (Part 3) Carcinoma of the pancreas. A. Sonogram showing pancreatic carcinoma(P), dilated intrahepatic bile ducts (d), dilated portal vein (pv), and inferior venacava (IVC). B. Computed tomography scan showing pancreatic carcinoma (darkarrows). C. Endoscopic retrograde showing abrupt c utoff of the duct of Wirsung(arrow). D. Magnetic resonance cholangiopancreatography showing obstruction(Obs) in the pancreatic duct (PD). The gallbladder (GB), hepatic duct (HD), andcommon bile duct (CBD) are labeled. Tissue Diagnosis and Cytology Patients with disease that is potentially curable by surgery, and in whom ahighly suspicious lesion is seen on imaging, are often taken directly to surgerywithout prior tissue confirmation of cancer. This is because of theoretical concernsthat a percutaneous fine-needle aspiration may result in dissemination of cancerintraperitoneally or along the track of the biopsy needle. In addition, negativecytology may not be sufficient evidence to avoid surgery, particularly with smalllesions. EUS-guided fine-needle aspiration is increasingly being used, even inpatients with potentially resectable disease, as there is less risk of intraperitonealspread of cancer. Other methods of obtaining specimens for cytological analysisinclude sampling of pancreatic juices or brushings of ductal lesions obtained byERCP. Serum Markers The most widely used serum marker in pancreatic cancer is cancer-associated antigen 19-9 (CA 19-9). It has a reported sensitivity and specificity ofabout 80–90%, and is suggestive, rather than confirmatory, of the diagnosis ofpancreatic cancer. Serum levels of CA 19-9 can be elevated in patients withjaundice without pancreatic cancer present. The level of CA 19-9 may haveprognostic implications, with very high levels sometimes found in patients withinoperable disease. In advanced disease, patients treated with chemotherapy whohad high pretreatment levels of CA 19-9 have also been found to have a worsesurvival, whereas those patients whose levels of marker fell with treatment had abetter outcome. In patients with cancers with elevated CA 19-9, serial evaluationof this marker is useful for monitoring responses to treatment. In patients withcompletely resected tumors, follow-up with CA 19-9 is useful for detectingrecurrence. Staging In pancreatic cancer, which has a poor prognosis, the value of detailedclinical staging is limited. The most clinically relevant distinction to make isbetween patients with disease that may be resected with curative intent, and thosewith advanced disease in whom treatment is palliative (Table 89-1). Table 89-1 Staging of Pancreatic Carcinoma Stage TNM Staginga Grouping Localized I T1–2 N0 M0resectable II T3 N0 M0 or T1–3 N1 M0 Locally advanced III T4 N(any) M0 Metastatic IV T(any) N(any) M1 a TNM, tumor, nodes, metastasis. Note: T1, tumor limited to pancreas, ≤2 cm; T2, tumor limited to pancreas,>2 cm; T3, tumor extends beyond the pancreas but without involvement of celiacaxis or superior mesenteric artery; T4, tumor involves celiac axis or the superiormesenteric artery (unresectable primary tumor); N0, no regional lymph nodemetastasis (regional lymph nodes are the peripancreatic lymph nodes, includingthe lymph nodes along the hepatic artery, celiac axis and pyloric/splenic regions);N1, regional lymph node metastasis; M0, no distal metastasis; M1, distalmetastasis. Source: Modified from Greene, Page; with permission. Surveillance in High-Risk Individuals Routine screening for pancreatic cancer is not recommended due to a highfalse-positive rate of the available tests. However, screening may be reasonable incertain high-risk individuals, such as those with strong family histories, althoughthe optimal timing, frequency, and method of screening is unknown. Onerecommendation is to commence screening at the age of 35 in patients withhereditary pancreatitis, or 10 years before the age of the youngest diagnosis ofpancreatic cancer in those with a significant family history using spiral CT,followed by EUS when CT results have been indeterminate.