Exocrine Pancreatic Cancer: Clinical Presentation, Diagnosis, and Treatment

00:01 So the clinical presentation.

00:03 If the cancer is in the pancreatic head, as I just said, and that's indicated there as that kind of brown stellate thing near the pancreatic duct.

00:12 And near the common bile duct, you get painless, obstructive jaundice.

00:16 It will be associated with elevated bilirubins with pruritus, itchiness and very light-colored stools, because you're not able to get bile into the GI tract to give the typical brown color to stool.

00:27 You may also see that the gallbladder is distended and enlarged because it can't dump its contents.

00:33 That will be the so called couvoisier sign.

00:35 There is an enlarged, palpable nontender gallbladder.

00:40 That's if you're lucky and unlucky is a relative term.

00:44 But in that case, you may pick up relatively small tumors very early in their course.

00:49 And it gives you the best chance of potentially doing a curative resection.

00:54 If on the other hand, the cancer is in the body and the tail, it's usually discovered only very late.

01:00 The pancreas can be remarkably silent in terms of masses and lesions.

01:05 Eventually, with extension of the tumor or metastatic disease, you may develop severe pain in the upper abdomen.

01:11 It may radiate to the back frequently with adenocarcinomas has in a variety of locations but very commonly in the pancreas, you'll see a hypercoagulable state, a so called Trousseau syndrome with evanescent thrombosis throughout the body.

01:30 So in addition to potentially having this pain, late and hypercoagulable state with significant tumor burden.

01:39 You can also eventually with metastatic disease involving the porta hepatis, the lymph nodes that sit near the head of the pancreas.

01:48 You can end up with portal hypertension as a result of the portal hypertension and the occlusion of the vasculature at that point, You may develop esophageal and gastric varices.

02:00 With very advanced disease there's typically a very profound and rapid downhill course.

02:06 With weight loss and anorexia associated with a tumor cachetic state.

02:11 Patients may present with brand new diabetes mellitus as they lose a lot of their islet mass due to the expansion of the tumor within the pancreas.

02:21 Clearly they're not making the appropriate enzymes that would be responsible for breaking down various ingested proteins, fats, sugars, so there'll be malabsorption with associated diarrhea.

02:36 Any intra abdominal tumor, gastric cancer, esophageal cancer, and pancreatic cancer is no exception, you may get a Virchow's node that's at the point where the thoracic duct dumps into the left subclavian vein.

02:49 And you get may get a prominent node at that point over the left clavicle.

02:54 And then you may have a retrograde tumor that goes into the umbilicus.

02:59 And around the belly button, the umbilicus, you may have a so called Sister Mary Joseph's nodule.

03:06 How do we make the diagnosis? Well, it's mainly the biopsy.

03:10 This is where your pathologist your friendly neighborhood pathologist comes in handy.

03:14 On the left hand side is the normal structure of pancreas.

03:19 So most of the cells that are present on here represent the acinar cells that are responsible for the exocrine pancreas, the pancreas secretions.

03:27 That one cleared out nodular area, kind of right in the middle of the picture is an islet.

03:34 So a pancreatic islet that's going to be responsible for making things like insulin and glucagon.

03:39 And then finally, you see the duct indicated there.

03:43 And that is lined by a cuboidal to low columnar epithelium.

03:48 And that's going to be the major source, those cells are the major source of pancreatic exocrine carcinomas.

03:56 On the right hand side is what this evil, evil tumor looks like.

04:01 And there are glands, kind of ill defined glands, with very atypical cells surrounded by a very dense, fibrous stroma.

04:11 And that's that desmoplastic response.

04:15 Once we made the diagnosis, what do we do about it? So, surgical resection is really our only hope in this particular case.

04:26 In the event that there has been no invasion of vessels, there has been no apparent metastatic disease, which is a minority of the patients.

04:33 We will often give neoadjuvant therapy upfront chemotherapy, do our resection and then do adjuvant chemotherapy afterwards.

04:42 And even in the very best of circumstances, small surgically resectable tumor, no invasion metastatic disease, the median survival is less than 2 years.

04:53 So I said this is a bad tumor.

04:54 I'm not telling you stories.

04:57 If there's locally advanced disease, you know, the long term kind of outlook is even worse.

05:05 So we will definitely do chemotherapy before and after any potential surgery.

05:11 And the median survival is less than a year.

05:14 And with distant metastatic disease, we're talking the same thing.

05:17 We can give systemic chemotherapy but most of our therapies just do not work.

05:22 The overall five-year survival all comers and if you talk, you know, look at the various percentages of minimal disease and locally advanced disease etc.

05:31 The overall five year survival all comers with pancreatic cancer is 10% or less.

05:39 The typical classic surgical procedure that we can try to do is called a Whipple procedure.

05:44 So a pancreaticoduodenectomy.

05:47 And what we're going to do what's shown on the left hand side, we're going to cut out the tumor at the head of the pancreas.

05:52 And we are going to reroute the bile ducts into a loop of the duodenum.

05:59 So we can get normal biliary drainage.

06:02 We're not going to get rid of all of the pancreas, we're going to have the pancreas and its duct connected up to that portion of duodenum.

06:09 And then we're going to do essentially gastric bypass surgery, dumping post antrum into kind of a secondary or tertiary loop of the duodenum.

06:19 And we cut out the head of the pancreas, we cut out the gallbladder.

06:23 Frequently, we may also remove the spleen, the lymph nodes, and that portion of the loop of the duodenum.

06:29 You see there in gray on the left hand side.

06:32 That's a Whipple procedure.

06:33 It's a pretty amazing and very invasive and very destructive kind of surgery.

06:41 And, as you saw, even with a Whipple procedure, the outcome is not a happy one in most cases.

06:49 So if everything is node negative and it's all perfect, 5-year survival is about 30%.

06:55 If there is a node that is found to be positive at the time of surgery, it goes less than 10%.

07:00 And remember, I said all comers survival at five years is less than 10%.

07:06 And with that, sorry, it's kind of a sad, depressing tale.

07:10 But for those of you who want to go into oncology, those who want to find an important kind of way to help your patients, figuring out a better way to treat pancreatic cancer will go a long way.

07:22 We do not do a good job right now.

07:24 And with that, I'll close.