Tumors of the pancreas


 * benign tumors occur very rarely
 * lipoma, cystadenomas, dermoid cysts, teratomas, apudomas
 * cystadenomas tend to malignate, they are removed
 * malignant tumors – we distinguish ampular tumors and then pancreatic cancer

Regional pancreatic lymph nodes

 * upper group - overhead and body
 * lower group - under the head and body
 * anterior group - pancreatoduodenal, pyloric and proximal mesenteric nodes
 * posterior group - posterior pancreatoduodenal, pericholedochal, mesenteric
 * lienal group - nodules in the hilus of the spleen

Ampullar (periampullar) tumors

 * most often it is a well-differentiated adenocarcinoma with papillary exophytic manifestations
 * used to be a rare rarity, today it is the fifth most common cause of cancer death
 * affects people over 50 years of age
 * prognostically favorable is that it soon manifests as obstructive jaundice - therefore it is indicated up to 4 times more *often for resection than pancreatic head cancer
 * metastases occur later

Carcinoma



 * according to the location we recognize - carcinoma of the head, body and cauda pancreas
 * occurrence
 * is increasingly common (currently about 2 times more than in the interwar period)
 * make up over 10% of GIT malignancies, over 3% of all malignancies
 * causes - a number of predisposing factors are known - obesity, alcohol, smoking , DM , biliopancreatic reflux, chronic pancreatitis
 * localization - 65-70% is in the head, 15% in the body, 5% in the cauda area
 * histology - 90% are adenocarcinomas of the ductal epithelium, acinar cell carcinoma has a very poor prognosis

stages of the tumor process

 * stage I - T1 or 2, N0, M0
 * stage II - T3 (infiltration into the stomach, blood vessels), N0, M0
 * stage III - any T, N1, M0
 * stage IV - any T, N, but M1

Clinical picture

 * initially presents as:
 * "discomfort" syndrome - anorexia, fullness, weight loss and indigestion
 * these symptoms should lead to the suspicion of pancreatic malignancy
 * pain - in the abdomen and banded in the back
 * in head tumor - obstructive jaundice - typical painless onset

Diagnosis
Imaging methods are crucial in diagnosis:
 * contrast X-ray - typical enlargement of the duodenal window "C"
 * USG - identifies the tumor mass, enables FNAB
 * ERCP - imaging functions and pancreatic juice collection for cytology
 * CT
 * arteriography - important for determining tumor operability (infiltration of ports or mesenterics - almost this precludes radical performance)
 * oncomarkers - CEA, CA 19-9, CA 50
 * differential diagnosis(dif.dg) - benign tumors, pancreatic pseudocysts, chronic pancreatitis

Therapy
Therapy is optimally surgical:
 * Whipple surgery - in case of head injury - cephalic partial duodenopancreatectomy
 * cauda involvement - left resection of the pancreas
 * total duodenopancreatectomy, tube connection gastrojejunoanastomosis
 * palliative:
 * in bile duct oppression - biliary anastomoses (see above)
 * at imminent duodenal oppression - gastrojejunoanastomosis
 * postoperative measures - glycemic control, or iatrogenic DM therapy - this diabetes is very difficult to control due to the absence of glucagon! - great tendency to hypoglycemia !!!
 * pancreatic enzyme substitution
 * adjuvant - percutaneous conventional RT, it is not very sensitive to CHT, it is used only palliatively

Prognosis

 * very unfavorable, operational lethality is 5-15%
 * in early diagnosable cancer, 5-year survival is still only 3%