Pancreatic cancer:
 
personal notes of Dr.. Claudio Italiano, gastroenterologist hospitals
Who writes on its experience, has had several patients with this severe form of cancer for which early diagnosis or knowledge of a genetic predisposition and family are the foundation of successful therapy. In fact, if you know of a sense of familiarity in the development of cancer, you must submit to screening and prevention appropriate family members. This writer, unfortunately, after a long time, has managed the diagnosis of a man treated for ulcers and found suffering from irritable bowel syndrome! Let us remember that the cure is always the last act of a diagnostic! To this gentleman, having performed an ultrasound and a CT abdomen and that, therefore, a magnetic resonance imaging, was found a suspicious lump. Performed a targeted biopsy, but the tumor was found already extended to the vessels and the peritoneum. The same was treated and palliation, the best thing to say is that he was concerned about the health of loved ones, until the end because he had an account of illness that gripped him.
Epidemiology.

The risk of developing pancreatic cancer increases with age, so that before age 60 are rare: Apennines in 15% of cases, 50% spread, however, between 60 and 80 years, 25% of cases spread over 80 years.

The causes of pancreatic cancer include:

Hereditary in 10%, or if there is familiarity, if the father is ill, his son will become ill.

In 30% of cases it is always smoking smoking is a major cause of cancer of the pancreas and beyond.

Benign lesions in the 4% of cases

The diet in 20% of cases contributes to the etiology.

In 36% of cases you do not know why.

And we mean when we talk about diet, high consumption of meat, foods high in cholesterol, fried foods and nitrosamines with sausages (eg salami), while fruit and vegetables seem to reduce risk. Even obesity, weight and general lack of physical activity play a key role, it was shown that obesity is frequently associated with pancreatic cancer (Michaud et al. JAMA, 2001;

A recent meta-analysis about the occupational risk to develop cancer (from exposure to environmental carcinogens) was conducted in 92 studies, grouping 23 carcinogens, showed that the substances are responsible for developing segienti in percentages:

· CHC solvents 1.4%

· Nickel compounds in nickel with 1.9%

· Chromium and chromium compounds 1.4%

· Polycyclic aromatic hydrocarbons 1.5%

Insecticides · organocloridici 1.5%

· Silicon powder 1.4%

· Solvents of aliphatic hydrocarbon and alicyclic 1.3%

Cystic fibrosis and cancer.

Cystic fibrosis plays a role, since cancer is a very rare event in patients with cystic fibrosis. Cancer in these individuals is five times more frequent than the general population, but people with cystic fibrosis are less than 40 years, or less of subjects suffering from pancreatic cancer, so this is not significant reduction of incidence. Since the age of these subjects tends to rise over time, probably cancer may become more frequent in these populations.

Genetic mutations and pancreatic cancer.

Lal and colleagues studied 102 cases of cancer of the pancreas in Ontario. Based on the history of their family, 38 of these patients were classified as high risk for a genetic mutation identified in 5 of them (1-p16, the BRCA1-and BRCA2-3). Four of these patients have associated cancer with this mutation. Known cause of genetic predisposition are important factors in only a small percentage of tumors of the pancreas. In these subjects because of smoking or not is due to early development of cancer in a study that proved as 16 subjects who developed cancer were smokers, and others who were not only developed it after 20 years in the ' (Lowenfels et al. JAMA, 2001). The effect of these mutations and to study these genetic predispositions is that they are to be screened.

Histology

Malignant tumors are the most frequent tumors of this body, representing 2% of all malignancies and 10% of those of the gastrointestinal.
The malignant tumor of the pancreas, or carcinoma is more common in men and in women (ratio 1.5:1) and in recent decades has presented a significant increase in frequency. Benign tumors are rare, accounting for 60-10% of neoplasms of the pancreas. The most frequent are divided into:

Solid serous cystic adenomas
solid mucinous cystic adenomas

These tumors must be differentiated from simple cysts that often appear in patients with a history of pancreatitis (inflammation of the pancreas).
Extremely important is the early diagnosis of mucinous cystadenoma is considered as a possible precursor of cancer. More often appears in the 6th decade of life and is currently the 4th-5th cause of cancer death in Western countries.


We distinguish:

Ductal adenocarcinoma (75-90% of cas, the most common) The most frequent localization is dependent of the head (65%), while more rare is the involvement of the body (30%) and tail (5%).

Mucinous adenocarcinoma

Acinar cell carcinoma

Adenosquamous carcinoma

Anaplastic carcinoma

Carcinoma cells with signet

Carcinoma mixed endocrine cells and ductal

Giant cell tumor-like osteoclastic

Mucinous cystadenocarcinoma

Intraductal papillary carcinoma

Pancreatoblastoma

Cell carcinoma solid pseudopapillari

The symptoms most commonly occur in pancreatic cancer are:

pain

dyspepsia (digestive slow, laborious, nausea, vomiting)

weight loss

jaundice (yellowing of the skin, as the side represented by our case report)

ascites in end-stage for peritoneal metastasis (ascites tumor)

1 The pain occurs for infiltration or compression of the nerve plexus, and is a pain like "belt", assumes that a distribution with involvement of upper quadrant abdominal irradiation and back to back, around the waist of a person.

Dyspepsia, the most frequent cancer in the head, is generally characterized by anorexia, nausea, vomiting and beehive irregularities (constipation alternating with diarrhea).

Weight loss is not always present, is related to dyspeptic symptoms described above as well as malabsorption resulting from the impaired function of exocrine pancreas.

Jaundice is a more consistent and early sign of cancer of pancreatic head (80-90%) but much less frequent and late in tumors of the pancreatic body and tail. E 'due to compression and / or invasion of the bile duct and is associated with itching, stool and urine ipocoliche hyperpigmentation.

The appearance of most common presentation of cancer of the pancreas is a hard nodule that invades surrounding tissues and it is clear a net margin. In the case of cysts you will detect the presence of groupings and microscopically well demarcated internally containing liquid material and / or mucous.


Diagnosis

Tumors of the pancreas are difficult to diagnose, especially in the early stage because symptoms are often very hazy and nonspecific. In addition, the pancreas is located deep in the abdomen and is thus difficult to study by conventional instrumental methods. These include:
laboratory tests - tumor markers CEA and CA 19.9
radiological:

ultrasonography - is the first survey instrument, easy to use. Possible to evaluate the bile ducts (for the presence of stones) and changes in morphology in the structure of the pancreatic gland.

CT abdomen - this test allows proper assessment of the lesion.

MR cholangiopancreatography - often the integration of CT. Permits evaluation of vascular structures adjacent to the tumor and the morphology of the pancreatic duct of Wirsung.

ERCP (endoscopic retrograde cholangiopancreatography) - this survey through the injection of contrast medium directly into the urinary tract (bile duct-bile duct and pancreatic duct) is extremely reliable and accurate.

Biopsy - phased out for the increasing reliability of the instrumental and the risk of dissemination of neoplastic cells along the needle passage.

When operate?

And 'contraindicated if you are:

· Liver metastasis, peritoneal distance

Infiltration · vascular obliteration (axis mesenteric-portal, superior mesenteric a., hepatic a.)

· Relatively contraindicated if there is a portal-mesenteric axis tangential involvement and infiltration of duodenum and colon of the cave pyloric.



In any case, the excision must be complete, with resection margins free of tumor (VBP, isthmus-body area, posterior pancreaticoduodenal, retroperitoneal margin), the extended lymphadenectomy to the level II lymph nodes, removal of self extrapancreatic nerve plexus (plexus capital , the A complex. pancreaticoduodenal)

Surgery is currently the only effective treatment in this condition. The 5-year survival does not exceed 6% for tumors of the pancreatic head, while for tumors of the papilla of Vater is 40% (usually the diagnosis is early for the immediate onset of jaundice). Radical resection depends on the location of the tumor, but given the increased frequency of cancers of the head of the pancreas is the most common intervention duodeno-cephalo-pancreatectomy, which is the removal of the duodenum with the head of the pancreas, bile terminal and possibly the last portion of the stomach (pylorus). Together all regional lymph node are removed........

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