GIT Tumor

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GIT Tumor

CARCINOMA OF PANCREAS

 Incidence: More in males above 50 years.

 Predisposing factors : Factors increase risk include smoking ,

alcohol , obesity , chronic pancreatitis , diabetes and cancer pancreas
in first degree relatives .

 Pathology:

❖ Site:

a) Cancer head : 60% .

• 2/3 of these cases arise in the head proper .

• 1/3 of these cases is periampullary carcinoma which arises

either from main pancreatic duct, ampulla of Vater ,
major duodenal papilla or the lower end of CBD .

b) Cancer body and tail : 40%.

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GIT Tumor

❖ Gross picture: Hard, irregular, ill-defined infiltrating mass.

❖ Microscopic picture: Adenocarcinoma arising from the duct

system with variable degree of differentiation.

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GIT Tumor

 Complications:
1. Spread:
a) Direct : to the
• The earliest infiltration of cancer head is to C.B.D
producing O.J .

• Cancer head later on infiltrate portal vein , superior

mesenteric vessels , IVC , pylorus & duodenum , transverse
colon and finally nerves on the posterior abdominal wall.

• Cancer body & tail of pancreas may infiltrate body of

stomach , splenic vessels , spleen , peritoneum.
* Relations of head of pancreas *

1st part of the

duodenum Neck of pancreas

2nd part of the

duodenum
Transverse colon
Superior mesenteric A.

Uncinate process of head of

pancreas
Head of pancreas
4th part of the duodenum
3rd part of the
* Anterior relations: duodenum
Common bile duct

Renal veins
Uncinate process

Abdominal aorta
Right kidney I.V.C.

* Posterior relations
* Relations of neck of pancreas *
Portal V. Splenic V.
Pyloro-duodenal junction

Superior mesenteric V.
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* Anterior relation * Posterior relation
GIT Tumor

b) Lymphatic: by permeation and embolization.

❖ Cancer upper part of head , neck , body , tail & to
pancreatico-splenic , pyloric and hepatic lymph nodes
→ coeliac lymph nodes → gastrointestinal lymph trunck .
❖ Cancer lower part of head & uncinate process to superior
mesenteric lymph nodes . → gastrointestinal lymph trunck
❖ From gastrointestinal lymph trunck spread can occur to :
1- Cysterna chyli→ thoracic duct → retrograde lymphatic
permeation → left supraclavicular lymph nodes
( Virchow’s gland ) ( positive Tourosie's sign ).
2- Retrograde spread in the lymphatics along hepatic artery
→ L.Ns. in the porta-hepatis → lymphatics around
ligamentum teres→ umbilicus ( sister Joseph nodule )

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GIT Tumor

Positive Tourosie's sign

Sister Joseph nodule

c) Blood spread to the :( 2L+2B or LBLB )

1- Liver mainly : metastasis from cancer head pass mainly to

the right lobe of liver while cancer body and tail to the left
lobe of liver .

2- Less commonly to lung, bone and brain.

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GIT Tumor

d) Transcoeloemic → peritoneal nodules especially in Douglas’

pouch, krukenberg’s tumour (in ovary ) and malignant ascites.

2. Obstruction of: C.B.D., duodenal or pyloric obstruction ,

portal vein & I.V.C.
3. Pacreatic asthenia: due to steatorrhea & pancreatic enzyme
deficiency.
 Clinical picture:
I) Carcinoma of head :
1. Malignant obstructive jaundice is usually the earliest
manifestation of cancer head :
▪ Classically, elderly male presents with painless O.J and pruritus .
▪ Jaundice is usually olive green .
▪ The condition is gradual , progressive with no remission,
except in periampullary carcinoma one or 2 remissions may
occur due to sloughing of a part of the tumor with passage of
bile.
2. Pain: a late presentation, due to obstruction of main pancreatic
duct or compression of retroperitoneal nerves. It is usually felt in

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GIT Tumor

the epigastrium and the back. At 1st it is increased on lying

supine and relieved on leaning forwards but later on becomes
severe and persistent .
3. Abdominal Swelling: epigastric , hard , irregular ill-defined
mass. It is at first mobile and later on becomes fixed .This
swelling is usually metastases in the left lobe of liver or lymph
node metastases and rarely pancreatic mass .
4. The liver is usually markedly enlarged because it is engorged with
bile and liver metastasis .
5. The GB is usually enlarged and felt (Courvoisier's law)
6. Very late loss of weight , superficial thrombophlebitis migrans,
features of metastases ( mention ).
II) Carcinoma of body and tail :
1. Present late by non specific symptoms as anorexia , loss of weight
, weakness , epigastric pain radiating to back .
2. Manifestation of metastases .
III) Mnifestations of dissemination and distal metastases in late
terminal cases : ( mention in any malignancy )
1. Abdominal masses (enlarged L.Ns & peritoneal nodules).
2. Liver metastases : jaundice with enlarged, hard, nodular &
tender liver.
3. Lung metastases : chest pain , dyspnea , cough & haemoptasis ,
malignant pleural effusion .
4. Bone metastases : bony pain , bony swelling & pathological
fractures .
5. Brain metastases : headache , repeated projectile vomiting &
blurring of vision .

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GIT Tumor

6. Malignant ascites : Marked ,tense & aspiration show

hemorrhagic ascites containing malignant cells and rapidly
accumulate .
7. P-R and P-V examination: may show pelvic deposits or
krukenberg’s tumor .
 D.D. : ( see obstructive jaundice )
1- other causes of jaundice ( see medicine )
2- calcular or malignant O.J
3-Chronic pancreatitis .
 Investigations:
1- Serum bilirubin and liver function tests (see O.J) .
2- Tumour markers :
▪ CA19-9 help to confirm the diagnosis if pancreatic cancer is
suspected , evaluate response to treatment and follow up of
the patient .
▪ Carcinoembryonic antigen ( CEA ) is the tumour marker for GIT
tumours .
3- Abdominal U/S :
▪ Uaually fails to show pancreatic tumour due to overlying
colonic gas .
▪ Confirm extra-hepatic obstruction by dilated intra-hepatic
and extra-hepatic bile ducts .
▪ Exclude calcular O.J .
▪ Show liver metastases or malignant ascites.
4- Abdominal CT scan :
▪ It shows pancreatic tumour as hypodense lesion .

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GIT Tumor

 NB : Presence of hypodense lesion with high level of CA19-9 is

diagnostic for cancer pancreas .

▪ It shows size , local extent of the tumour .

▪ It shows invasion of surrounding structures .
▪ It shows liver & lymph nodes metastases .
▪ In suspicious diagnosis , it allows percutaneous fine needle
aspiration biopsy .

5- ERCP :

▪ It show site of obstruction and differentiate calcular from

malignant obstruction of CBD .

▪ Biopsy from ampullary or pancreatic ducts can be taken .

▪ Insertion of stent which may be temporary preoperative for

operable cases or permanent in inoperable cases .

6- Endoscopic U/S : Shows local spread for accurate staging and

allows to take biopsy .

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GIT Tumor

7- PET scan & PET-CT show the 1ry tumor and to assess nodal and
distal metastases .
6. Barium meal: (rarely done nowadays)
a) Cancer head of pancreas → widening of C shaped duodenum.
b)PeriampuJary carcinoma → inverted 3 appearance of duodenum.

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 GIT Tumor

* Prognosis:
▪ Depends on degree of differentiation , depth of infiltration ,
presence of lymph node metastases , infiltration of surrounding
structures or distal metastases .
▪ The prognosis of periampulary carcinoma is better than the
cancer in the head proper because it present earlier by O.J while the
tumor is very small . In contrast to cancer body and tail which are
diagnosed very late .
▪ Very poor, 5 years survival is only 5% of patients.
* Treatment:
A. Operable cases: ( potentially curable ) (less than 10%)
❖ Features: (mention in any malignacy)

1- Clinically & investigations: localized mobile tumour, no peritoneal

nodules, no malignant ascites, no evidences of distal metastasis and
the patient is fit for surgery.

2-At laparotomy: the first step in the operation is exploration to assess

the operability. The tumour is operable if it is localized to the organ
with no invasion of important surrounding structures, no ascites or
peritoneal nodules and no liver metastasis.

❖ Preoperative preparations: (see O.J.)

❖ Method:
I) Surgery :
1. Carcinoma of head : Pancreaticoduodenectomy (Whipple’s
operation).
▪ Removal of the head and neck of pancreas , whole
duodenum and pyloric region , GB , lower part of C.B.D. and
draining L.Ns.

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GIT Tumor

▪ Restoration of the continuity by anastomosis of the end

of stomach, pancreatic duct & end of C.B.D. to the jejunum.
2.Distal pancreatectomy: For cancer body and tail.
▪ Removal of body and tail of pancreas, spleen and associated
L.Ns.
II) Adjuvant chemotherapy may be given before or after surgery
but adenocarcinoma is radioresistant .

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GIT Tumor

B. Inoperable cases: (more than 90% of tumours are unresectable)

❖ Features: (reverse of operable cases clinically & laparotomy)
❖ Methods: Palliative measures
1. Recently, endoscopic stenting through the occluded
C.B.D. at E.R.C.P.

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GIT Tumor

2. If stenting fail ------► Cholecystojejunostomy with

jejuojejunostomy to prevent passage of intestinal contents to
the G.B.
3. Gastrojejunostomy: is indicated for pyloric obstruction.
4. Palliative Chemotherapy.

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