NEOPLASIAS DE PANCREAS Dra Marianella Madrial Borloz HOSPITAL MEXICO

AUNQUE NO SE HAN IDENTIFICADO CAUSAS ESPECIFICAS..... Factores relacionados con : Alto riesgo: Bajo Riesgo: Edad, sexo 1. Frutas y Verduras Urbano 2. Historia de alergias Pobl negra (USA) 3. Amigdalectomía Clase econ Tabaco OH? Pancreatitis, Dieta: café, té,carne, grasa Fact ocupacionales: Rx, Qx Gastrectomía, DM

CLASIFICACION HISTOLOGICA. TUMORES EXOCRINOS

DIAGNOSTICO Figure 7-5. When the history and physical examination suggest the possibility of pancreatic cancer, the first diagnostic test the authors use a spiral computed tomography (CT) scan. If a pancreatic mass is detected, then the patient is evaluated for operation. If no mass is seen on CT scan, then the patient will undergo an endoscopic retrograde cholangiopancreatography (ERCP). If the ERCP demonstrates normal pancreatic and common bile ducts, then the patient may be observed with close follow-up. If the duct anatomy is abnormal, then the patient is evaluated for operation. Some endoscopists may also obtain endoscopic needle aspiration or duct brushings at this point as well. Patients are evaluated for operation on the basis of CT evidence for resectability and presence of metastases. If the CT scan demonstrates metastases or definite involvement of the major vessels (eg, portal vein or superior mesenteric artery) by tumor, the patient's diseases are classified as unresectable. Other factors that may influence whether or not a patient is an operative candidate are their ages and general overall medical condition. In patients determined to be candidates for operation, the use of laparoscopy as a first step is controversial. Advocates perform laparoscopy to determine if there are any peritoneal or liver metastases present that were not detected by the CT scan. If metastases are present, laparotomy is avoided and the patient may undergo endoscopic stenting. If no metastases are detected by laparoscopy, the patient will undergo laparotomy. Intraoperative determination of resectability will then determine whether or not the patient is a candidate for a resection of the tumor or a palliative bypass procedure. If a patient is not an operative candidate, tissue confirmation of pancreatic cancer is the next step; this is done using CT- or ultrasound-guided fine-needle aspiration (FNA). Endoscopic FNA, biopsy, or brushings are also options. If the biopsy is positive, then the patient can undergo endoscopic stenting or be reevaluated for a palliative bypass. If the biopsy is negative, the patient can undergo laparoscopy and biopsy.

SINTOMATOLOGIA SINTOMAS SON TARDIOS, 1er PERIODO LATENTE Pérdida de peso (91 %) Dolor (83%) Ictericia ( 71%9 Anorexia,nauseas ( 44%) Otros: Malestar, vómitos, dis pepsia, cambios del hábito intestinal PANCREATITIS S. TROMBOTICO SDA NECROSIS GRASA DM TRAST PSIQUIATRICOS METASTASIS

EXAMEN FISICO HEPATOMEGALIA LEY DE COURVOISIER TERRIER MASA ABDOMINAL ESPLENOMEGALIA (C Y C) ASCITIS EDEMAS Ms Is ASOC A COMPLICACIONES

DIAGNOSTICO- LABORATORIO Bilirrubina, FA PFH alteradas Glucosa Amilasa, lipasa... Guayacos, Anemia, hipoprot Marcadores Tumorales: Ca 19-9, ACE,Ca 50,AFP, Antígeno Oncofetal Pancreático Marcadores Genéticos: p 52, K ras

GABINETE EGD ESTUDIOS BARITADOS ERCP ( 70-80 %), CON CITOLOGIA (92-95%) US (80%) TAC ( 80%) RESONANCIA MAGNETICA BX AGUJA FINA DIRIG POR TAC ANGIOGRAFIA, GAMMA LAPAROTOMIA

ESTUDIOS BARITADOS Figure 7-7. Barium studies of the gastrointestinal (GI) tract are not often used to evaluate patients with suspected pancreatic cancer. Because many of these patients present with nonspecific gastrointestinal symptoms, however, an upper GI may be obtained. Findings on upper GI that suggest pancreatic cancer include extrinsic compression, displacement or encasement of the C-loop, mucosal invasion (nodularity or spiculation), or Frostberg's reversed "3" sign. A, Widened duodenal sweep and the suggestion of compression of part of the duodenal loop. B, Note the reversed "3" sign caused by the nodular compression of the medial duodenal wall by the pancreatic cancer. (Courtesy of Dr. Barbara Kadell, UCLA Department of Radiology.)

ESTUDIOS BARITADOS Figure 7-7. Barium studies of the gastrointestinal (GI) tract are not often used to evaluate patients with suspected pancreatic cancer. Because many of these patients present with nonspecific gastrointestinal symptoms, however, an upper GI may be obtained. Findings on upper GI that suggest pancreatic cancer include extrinsic compression, displacement or encasement of the C-loop, mucosal invasion (nodularity or spiculation), or Frostberg's reversed "3" sign. A, Widened duodenal sweep and the suggestion of compression of part of the duodenal loop. B, Note the reversed "3" sign caused by the nodular compression of the medial duodenal wall by the pancreatic cancer. (Courtesy of Dr. Barbara Kadell, UCLA Department of Radiology.)

ULTRASONIDO. PTE CON ICTERICIA DE ORIGEN DESCONOCIDO Figure 7-8. Ultrasound can be a useful diagnostic modality to evaluate a patient with jaundice of unknown etiology. If the cause of the jaundice is biliary obstruction from a pancreatic tumor, the extra- and intrahepatic bile ducts are dilated. If the cause of the jaundice is intrahepatic, the ducts are of normal diameter. Ultrasound is inferior to computed tomography scanning both for tumor detection and staging of the disease. It is therefore not recommended for screening if pancreatic cancer is strongly suspected.

TAC, BIOPSIA DIRIGIDA Figure 7-11. A, Computed tomography (CT) can also direct a needle aspiration to obtain a tissue diagnosis from a pancreatic mass. B, Atypical cells, as seen on this CT-guided needle aspiration sample, signify the presence of pancreatic carcinoma. This procedure plays an important role in patients who are not operative candidates either because their tumors are not resectable or they are in poor medical condition. Confirmation of pancreatic cancer with tissue involvement can initiate palliative procedures, such as endoscopic stenting, chemotherapy, or reevaluation for an operative bypass. (Courtesy of Dr. Barbara Kadell, UCLA Department of Radiology.)

BIOPSIA POR ASPIRACION (TAC) Figure 7-11. A, Computed tomography (CT) can also direct a needle aspiration to obtain a tissue diagnosis from a pancreatic mass. B, Atypical cells, as seen on this CT-guided needle aspiration sample, signify the presence of pancreatic carcinoma. This procedure plays an important role in patients who are not operative candidates either because their tumors are not resectable or they are in poor medical condition. Confirmation of pancreatic cancer with tissue involvement can initiate palliative procedures, such as endoscopic stenting, chemotherapy, or reevaluation for an operative bypass. (Courtesy of Dr. Barbara Kadell, UCLA Department of Radiology.)

MASA EN CABEZA DE PANCREAS Figure 7-13. A, Computed tomography scan demonstrating a mass in the head of the pancreas. B, Massive intrahepatic biliary dilatation secondary to obstruction of the common bile duct resulting from the pancreatic tumor. (Courtesy of Dr. Barbara Kadell, UCLA Department of Radiology.)

DILAT INTRAHEPATICA SECUNDARIA Figure 7-13. A, Computed tomography scan demonstrating a mass in the head of the pancreas. B, Massive intrahepatic biliary dilatation secondary to obstruction of the common bile duct resulting from the pancreatic tumor. (Courtesy of Dr. Barbara Kadell, UCLA Department of Radiology.)

MASA EN CUERPO PANCREAS Figure 7-14. A, Computed tomography scan demonstrates a mass in the body of the pancreas with a dilated pancreatic duct distal to the mass. B, Endoscopic retrograde cholangiopancreatography in the same patient showing a stricture (between arrows) in the pancreatic duct with significant distal pancreatic duct dilatation. (Courtesy of Dr. Barbara Kadell, UCLA Department of Radiology.)

MASA EN CUERPO PANCREAS Figure 7-14. A, Computed tomography scan demonstrates a mass in the body of the pancreas with a dilated pancreatic duct distal to the mass. B, Endoscopic retrograde cholangiopancreatography in the same patient showing a stricture (between arrows) in the pancreatic duct with significant distal pancreatic duct dilatation. (Courtesy of Dr. Barbara Kadell, UCLA Department of Radiology.)

MASA EN COLA DE PANCREAS,TAC HELICOIDAL Figure 7-15. A, Spiral computed tomography scan demonstrating a mass in the tail of the pancreas. B, Close-up view demonstrates adherence of the mass to the splenic vein. (Courtesy of Dr. Barbara Kadell, UCLA Department of Radiology.)

LESION EN COLA DE PANCREAS Figure 7-15. A, Spiral computed tomography scan demonstrating a mass in the tail of the pancreas. B, Close-up view demonstrates adherence of the mass to the splenic vein. (Courtesy of Dr. Barbara Kadell, UCLA Department of Radiology.)

AMPULLOMAS MEJOR PX COLEDOCO TERMINAL,AMPULLA,PARED DUODENAL, PORCION DISTAL DEL WIRSUNG SINTOMAS: ICTERICIA, MELENA, COLANGITIS TRATAMIENTO QX

TUMORES ENDOCRINOS DEL PANCREAS Nombre Sínd Sg, S+ Local. Hormona Insulinoma S+ hipoglic Panc 97% Insulina Gastrinoma Zollinger-Ellison Dolor abd, diarrea, s+ esofàgicos Panc 60% Duod 30% gastrina Glucagono ma Rash,anemia, DM,PePeso.. Pancreas glucagón VIPoma Verner-Morrison Diarrea acuo sa severa Páncreas (90%) PIV Somatosta tinoma DM, colelit,esteat Panc 56% ID 44% tina GRF oma idem Acromegalia Fact Lif HC PPoma Pepeso, masa abd, hepatom No