Tumors of the pancreas

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• 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

 For more information see Pancreatic carcinoma.

Pancreatic head carcinoma after contrast application of CT

• 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

Terapie

• optimálně je chirurgická
• Whipplova operace – při postižení hlavy – kefalická parciální duodenopankreatektomie
• postižení kaudy – levostranná resekce pankreatu
• totální duodenopankreatektomie, spojení trubice gastrojejunoanastomózou
• paliace
  • při útlaku žlučových cest – bilidigestivní anastomózy (viz výše)
  • při hrozícím útlaku duodena – gastrojejunoanastomóza
• pooperační opatření – kontrola glykémie, příp. terapie iatrogenního DM – tento diabetes je velmi těžce ovlivnitelný pro absenci glukagonu! – velké tendence k hypoglykémiím!!!
  • substituce pankreatických enzymů
• adjuvance – perkutánní konvenční RT, na CHT je ca málo senzitivní, používá se jen paliativně

Prognóza

• velmi nepříznivá, operační letalita je 5–15 %
• u včas diagnostikovatelného karcinomu je 5-leté přežití stále jen 3 %

Odkazy

Zdroj

Kategorie:Chirurgie Kategorie:Onkologie