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Yeah. Okay. Yeah. Mhm. All right. Yeah. Well, I okay. Uh Good evening, everyone. Thanks very much for joining us on Thursday evening here at Strip to very, very glad to have Sherry here to talk about pancreatic cancer as part of the, the G eye surgery week this week. Uh Yeah, it should be a fantastic and interesting topic and we thank her very much for time. Uh Yeah, take it away, Sherry. So, hi, my name is Sherry. I'm one of the fourth year medical student from Glasgow and they were gonna talk a little bit about pancreatic cancer. So I would do a brief, introduced introduction on the anatomy of the pancreas from position structure duct system and vasculature. And then we will go, we will dive into pancreatic cancer. So from uh definition pathophysiology, theology, presentation investigation and then treatment. I have a short case at the end that we can walk through. So let's start with the anatomical position of pancreas. So the pancreas is located deep within the upper abdomen um in the epigastrium and the left hypochondria mom region and it lies transversely in the abdomen between the duodenum and on the, on the right and the spleen on the left. So well, usually the pancreas is divided into the head, neck body and the tail. Um I got this picture from teaching anatomy and then they further they have this like usin eight process. But I think the key bits, our head, neck body and tail. So the headlines on the inferior vena cava and the reno veins and it is surrounded as the picture show, it is surrounded by the sea loop of the duodenum. The pancreas is retro peritoneum, Tony away organ besides the tail. So the tail is actually in front and then we have the doc system. So um little recap on what the pancreas do. So you have eggs, a crime function and endocrine function and endocrine pancreas is classified as a local latest yours gland which produces your digestive enzyme precursors. And um it is composed of uh very light cluster cells called Cassini Cassini. Seen I and it is then connected into a network of intralobular collecting dogs. And these dogs then turned into the main pancreatic duck. And as the picture shows here, the pancreatic duct then connect with the common bile duct and then they will pass it through the hip ato pancreatic and pillow elevator, which is controlled by a muscle splint er called the sphincter of oddi, a muscle valve called the sphincter of all deep. So, yeah, so that is the dark system of the pancreas and then we'll have the vasculature of the pancreas, all the pancreas um you can look at is as the head and the rest of the pancreas. So the head of the pancreas is supplied by um the superior and inferior pancreas, pancreas attic code, your denial artery is a mouthful to say which are branches of the gastro Judy know and the super superior mesenteric arteries. So the head has a lot of vascular supply. Well, the rest of the pancreas is supplied by branches of the splenic arteries, right? Ok. So that is the arterial supply and then we move on to the venous drainage. So again, you will separate into two. So the head is drains into the superior mesenteric branches of the hip hot ick, Port Hovan, and the rest drains to the splenic veins. So it's like where you get your arterial supply is where you drain your venous. Okay. So that is the basic anatomy of the pancreas. So now we will move on to talking a little bit about what is pancreatic cancer and what are the possible physiology. So, pancreatic cancer are more than 90% are pancreatic ductal adenocarcinoma. And we're not really gonna talk about the 10%. So majority are from the docks and there are some series about how these lesions come across. So you have to um precursor lesion, you can think about it like pre neoplastic states. So, introductory, popular very musician iss Neoplasm and the Muse Ennis Cystic neoplasms. So that these are the two and um 65% of the tumor are located at the head. And I think it's because you get a much better arterial supply like a better vascular system at the head. And the rest is like 15% in the body, 10% in the tail and 10 multifocal um lymph node, metastases are really common, especially within the abdomen and some distant metastasis sites include liver, lung, skin and brain. So, and then we'll talk about a little bit about epidemiology and the theology. So, pancreatic cancer is the seventh most common cause of cancer related deaths in the world. Um It is quite a deadly cancer with very poor prognosis as um this disease, this cancer is usually picked up at the much later state compared to other cancers such as lung cancer or breast cancer. Um It's also referring as the disease of the old with a peak of 60 to 75 years old of age. So that is your majority of patient group. And okay, we'll talk about risk factors. So I separated into modifiable and non modifiable risk factors and I think this applies to most disease. It will make it much clearer if you organize it this way. So modifiable straight four cigarette smoking alcohol. And I put a parentheses of chronic pancreatitis. Uh I think everybody knows like alcohol will have, will lead to a greater possibility of pancreatitis, acute pancreatitis, which then can progress into chronic pancreatitis. Um I have a step point here. So there's like 4% risk. Um There's a 4% risk over 20 to 30 years of patient's developing pancreatic cancer if they have chronic pancreatitis and disproving this cancer in these patient's will be very difficult. Um Did you calcifications and further complications and um non modifiable risk factors? And are your genetic stuff, which is hereditary pancreatitis to your M E N to um syndromes Lynch syndromes like P 53 mutations, right? And there is a UK based screening trial for these um familial pancreatic cancer called the Euro pack. And if patient meet the certain criteria, they will be offered annual bloods and imaging such as CT or MRI screening to prevent um you know, to increase the prognosis basically. Okay. I have like some other like horrible um poor prognosis here. So like most of the patient's have lower than five year of survival rate which is disheartening and um only a minority. So like 5 to 10% patient will get um curative surgery. We will talk about treatments later because like they're usually detected late. So surgery might not be an option for them. They will need to go for supportive treatment, which is not curative obviously. And yeah, if you have metastases, you will have even lower survival rate. So, okay. That is that. And now we will talk about presentations. So in early stages of pancreatic cancer, you might not have the classic signs of painless jaundice or they might just be presented as nonspecific symptoms such as fatigue, abdominal pain, nausea, vomiting, and non specific weight lost. It is later in advance stage. When the tumor progressed, uh started obstructing the common bile duct, then you will get the obstructive symptoms, objective jaundice symptoms such as pale stool, dark urine, pariah tous itchy skin as you may call it. Um the pain will be very similar as what you see in q pancreatitis. It's an epic gastric pain radiating to the back. Um So yeah, it is important to know that even though we most likely say, oh it's a painless John this but patient's can also present with pain. Uh yeah, and then to think of just going back to what the pancreas do. So you have your extra crime function, your endocrine function. So extra prime function dysfunction will lead to malabsorption. See a toria on explained episodes of pancreatitis, weight laws such and such an endocrine dysfunction would be something like a new onset of diabetes, pancreatic diabetes. And um another point is that you will have increase of scramble, amble embolic disease, not exactly sure why but something to look out for. So, so two scenarios will make you really worried about pancreas, pancreatic cancer. The first one is the in like an older patient, painless obstructive jaundice, think pancreatic cancer and a new onset diabetes without predisposing features or any positive family history will also make you think about um pancreatic cancer. All right. Okay. So, moving on to investigations, we'll just give you a brief overview. So you're not lost in my voice. So we will talk about laboratory tests, imaging, um non invasive imaging and invasive imaging and additional tests. So we're gonna start with uh blood test. So you will do your basic cutting profile, FBC and LFTs. LFTs is especially important because you want to establish the degree of obstructive jaundice. And also um think about other causes of explore other causes of painless jaundice like hip hop, it'll cellular causes, basically. And there are two tumor markers here. I listed see A 19 9 and see A 125 C A 99 is usually more useful. And um when you're looking at treatment responses and disease progression and seeing 1 to 5 more for um is more for disseminated disease like metastases and stuff. And one thing worth noticing um which add another layer of value to your LFT is that you should always interpret your see A 19 9 with your LFTs. Uh um because John this patient can present with very, very high, see a 99. But as the jaundice start resolving the value may fall and even normalized. So it is not diagnostic of pancreatitis, pancreatic cancer on its own. All right. And um another tumor marking might that might be useful, but there are still research going on in C A C E A. So yeah, that might change in a few times and then we'll talk a little bit about non invasive imaging. So, CT is your primary primary, primary, primary, primary tool of diagnosis. Um So you would always prefer a patient's over 60 years old with weight loss following by any of the symptoms such as diarrhea, back pain, abdo pain, vomiting, constipation, or new onset diabetes. You will refer them urgently because you're thinking pancreatic cancer it and other um imaging that might be useful would be MRI that would be your second line really. And um your ultrasound is only useful when the tumor is big enough and it's you can physically see the tumor or you can see the dilatation of your common bio duct other some other tests like M R A M R C P mhm less of a diagnostic tool, more like a staging tool. Um Okay. So these two pictures are not sure how, how well you can see them, but they're like they're pointing at the head of the, at the pancreas suggesting um a tumor there on the left image. So, CT the CT is the workhorse of pancreatic oncotic imaging. You would do a CT and pancreatitis as well and you will also do it in pancreatic cancer, obviously. Um Typically a ductal adenocarcinoma, which is 90% of the case, a pair as like poorly defined mass with extensive surrounding a dismal plastic reaction. So you see some swelling and um which is which could be, which is sometimes Hypoattenuating compared to the normal pancreatic um tissue. But it can also be isil attenuating in later scans. So it's not always 100% case, but one thing for like exam purposes and what they always ask in pass med is the double duck sign. So the double doc sign refer to the presence of simultaneous dilatations of the common bile duct and the pancreatic doc. You can also see the double doc sign in M R C P. Some common, the most common cause of double doc sign is pancreatic cancer. But you can also have less common cause such as M Q impute um pillory humor I the car carcinoma of the ampule A that Vater you can also have something like um chronic pancreatitis can also give you double doc sign and um um pillory stenosis. Basically anything that cause blockage and validation of the two dox. Another thing CT can pick up is calcification. Like I said earlier, chronic pancreatitis associated with calcifications um can predispose patient to pancreatic cancer, right. Okay. I think that's all I'm gonna say for the image, the non invasive imaging. So I'm moving on to the more invasive one. So you can have an endoscopic ultrasound. Um it's more sensitive than the normal trans abdominal ultrasound and picking up smaller tumor. Yeah. And you can also do an ultrasound, guided fine needle aspiration to obtain samples for grading but they are associated with, with higher rates such as peripheral ation infections, bleeding, um uh malignant seeding even. And also you can do an E ERCP to collect samples, cytology and place a stent for symptoms relief. We will talk about it and further details later and also additional investigations now and you can do a tissue diagnosis, but this is usually not required prior to surgical resection. And it's usually send after the surgery to produce a report and you can do genomic testing as we said earlier, the non non modifiable risk factors of pancreatic cancers. So you're Bracha M E N um P 16, such and such. Okay. So we'll talk a little bit about treatment now. So general principles of treatment is investigation and management should not be delayed in any patient. You suspect of pancreatic cancer and all patient should be prescribed with pancreatic enzymes, nutritional support, sub supplements to maintain weight and to increase quality of life. Treatment is based on the extent of the disease like different stages, metastases status and things like that. And I'm sorry. So you have some treatment option which is curative, um usually referring as surgical resection of the tumor or symptoms. Relieve um with palliative palliative surgery, chemotherapy, radiotherapy and stenting. So, in early stages of pancreatic cancer, uh the rule of some is that the tumor is not involved with a superior mesenteric artery, celiac acid axis or common hepatic artery. So it should be in a location that will not cause further damage to the patient and there should be no distance metastases. And um I'm not gonna go into detail of how you would do this surgery cause I feel like that would be something you should see in theater. And I'm not certain know surgeon to explain this. But the most common one would be the whipple and the transversally Longmire procedure, which depends on which, which is depending on the location of the tumor. So whipple would be ahead of pancreas and I the other one would be other places, right? And post surgery, you will think about um the and think about the anatomy again. So uh it is in close proximity to the jodi numb and the spleen. So you would like to preserve as much bio continuity as possible. And if there is potential spread of Matassa City to the spleen or damage the spleen, you would consider a splenectomy, right? Um uh got a feedback from one of the general surgeon. So they said that it is no longer like, oh, if you're a stage one or a stage two, then you can do surgery. If you're a stage three, it's definitely know with the events of chemotherapy and radiotherapy and it's like readily available for these patient's, you can do new a driven therapy prior to surgery to reduce the room tumor size and to the extent of the tumor. And then you can still perform surgery after that. So, it is really a case to case, um, discussion rather than the black and white theme. All right. Okay. That's fine. Uh, now we will talk a little bit about the more a fenced disease. So, um, if the tumor is involved in nearby structures, I either Juul Agena spleen liver or it's metastases, metastasized to further distance, then you would not consider surgery. You can still do palliative surgery like dissecting part of the tumor. Well, to relieve the obstruction, put some stent to um help the eggs are crime, build up of the pancreas and to relieve some of the pain. And you can also consider, consider chemo radiotherapy immunotherapies and such to help increase the quality of life of these patient's. Another thing was noticing is the pain control cause. Um these kind of pain might be a bit um unbearing. So you would like to involve palliative care, um even anaesthetics in these cases for better pain control. Right? Fine. Okay. Now, we will talk a little bit about this case. So this is a 58 year old female patient referred by the G P do too generalized weakness, uh itchy skin and itches Clara for a week on examination. She had a mild yellowish discoloration of the skin, you Khoza and Clara all over the body as well as a mild epic gastric non um rebound tenderness patient denied of any pain on palpations. So I'm not sure how interactive. This is but um maybe think about three differential diagnosis for this patient and think about three investigation that be requested. Okay, I think I'll just carry on. Um So your differential diagnosis for painless Rhonda's would be hepatocellular disease due to toxin medication, ischemia or infections or general biliary obstructions due to gallstones or pancreatic or biliary malignancies. Um It's more, less likely to be gallstones because gallstones will cause like more pain in this situation. So we will go on, go to the direction of pancreatic cancer. This is what this talk is about. Um So for investigation, I would order FEC calling factors LFTs and your two tumor for two tumor markers and also request imaging of CT MRI and MRI CP just to make sure there is not other causes of biliary obstruction due to gallstones or like cholangio carcinoma. And the but results came back. So you have an elevation in total billy Ruben and the vision of A L T and the two tumor markers are elevated as well. So it's more and more suggestive of pancreatic cancer. Okay. And then the CT report, um there was a mass shadow in the head of pancreas and you have your classic double tube sign and MRI and M R C P just further confirmed that there is a mass at the pancreatic head. Yeah, more likely of a pancreatic cancer for a further diagnosis. There are Abdulhamid, no metastases but no distant metastasis. So this is basically the report of the patient. So now I like to, to think about what is the diagnosis and um what is the disease progression and what are your treatment options for this patient? Awkward balls. Okay. We will move on. And so for this patient, it is uh from her history, her lab results and her imaging examinations, it is more suggestive of a locally advanced pancreatic cancer. So why? Because first of all, the C A 99 was significantly increased. I think I should have put in the LFT results, but I couldn't find it from the paper always interpreted with the context of of it LFT. This is a bad example anyways and the imaging shows a mass shadow and but supply to the tumor and then there's a present, the the double tube sign is present. And yeah, the pathology report showed there's Abdul lymph node involvement as well. So it will be classified as a like a T four and two. So kind of like a stage street for pancreatic cancer. And yeah, so the patient is later sent for palliative surgery and chemo radiotherapy supportive care as well as pain control. Oh, I got this case from a paper that I have cited in the reference page. So if you're interested, you can have a look or they're um I think that is the end of my talk, you have any questions you can put in the chat. I'll try my best to answer if not then thank you very much for your attention. Oh okay. Okay ground. Uh let's see. Okay, thank you for your attention. These are my reference list. Um Yeah. Okay. How do I stop sharing? Uh Right. Uh Sure. Uh huh. Uh yeah, thank you. Yeah. Mm Yeah. Anyways I'm gonna leave the call now. Okay and bye.