Câncer de pâncreas e vias biliares. Incidência Mortalidade 5ª causa de morte por câncer na...

Câncer de pâncreas Câncer de pâncreas e vias biliarese vias biliares

IncidênciaMortalidade

5ª causa de morte por câncer na América do Norte no ano de 2000

Câncer pancreáticoCâncer pancreáticoEpidemiologiaEpidemiologia

Pancreatite crônicaDiabetes MelitusAnomalias na junção dos ductos

biliopancreáticosHábito de fumarConsumo de café

Câncer pancreáticoCâncer pancreáticoGrupos de riscoGrupos de risco

ClínicoIcterícia – 50%Dor lombarPerda de pesoDiminuição do apetite

Câncer pancreáticoCâncer pancreáticoDiagnósticoDiagnóstico

ClínicoSinal de curvoisier-terrier

Câncer pancreáticoCâncer pancreático

DiagnósticoDiagnóstico

LaboratorialCA 19-9

DiagnósticoPrognósticoMonitoração

Câncer pancreáticoCâncer pancreáticoDiagnósticoDiagnóstico

ImagenológicoUS abdome superiorTC abdome superior

Câncer pancreáticoCâncer pancreáticoDiagnósticoDiagnóstico

TomográficosArtéria mesentérica superior livreVeia mesentérica superior livreTronco celíaco livre

Câncer pancreáticoCâncer pancreáticoCritérios de ressecabilidadeCritérios de ressecabilidade

Intra hepáticasExtra hepáticasVesícula biliar

Vias biliaresVias biliares

ImagenológicoUS abdome superiorTC abdome superiorEndoscopia digestiva alta com

duodenoscopia

TumoresTumoresperi-ampolaresperi-ampolares

DiagnósticoDiagnóstico

protocolo padrãoQU IMIO e R AD IO

protocolo alternativo

R ESSEC Ç ÃOcom linfadenectomia

C IRU R GIA

D R EN AGEMB ILIAR

PER C U TÂNIA

bilirrubina total> 20 mg/dl

bilirrubina total< 20 mg/dl

preparo paracirurgia

critérios deR ESS EC AB ILID ADE

D ER IVAÇ ÃOB ILIODIGESTIVAcom biópsia com

congelação

condição clínicaB OA

PR OTOC OLOALTER N ATIVO

FPT

AV ALIAÇ ÃOON C OLÓGICA

PR ÓTESEEN D OSC ÓPIC Acom biópsia ou

escovado

DR EN AGE ME XTE RN A

*

R TD ESOB STRU TIVA

*

condição clínicaR U IM

critérios deIR RESSEC AB ILID AD E

D IAGN ÓSTIC O:sugestivo de N E OPLASIA

C PR E

DIAGN ÓSTICO:sugestivo de doença

B EN IGN A

U Sendoscópica

ED Acom duodenoscopia

TCabdome superior

U LTR ASON OGRAFIAAB DOMIN AL

C OLESTASEEXTRA-H EPÁTIC A

TNM

Câncer pancreáticoCâncer pancreáticoEstadiamentoEstadiamento

CirúrgicoOperação de Whipple

LinfadenectomiaRadioterápicoQuimioterápico

Câncer pancreáticoCâncer pancreáticoTratamentoTratamento

IncidênciaMortalidade

Câncer de vesícula Câncer de vesícula biliarbiliar

EpidemiologiaEpidemiologia

SuspeitoInaparente

Câncer de vesícula Câncer de vesícula biliarbiliar

DiagnósticoDiagnóstico

CirúrgicoColecistectomia simplesColecistectomia com:

Segmentectomia hepática IV e VLinfadenectomia regional

Câncer de vesícula Câncer de vesícula biliarbiliar

TratamentoTratamento

Câncer pancreáticoCâncer pancreático

PrognósticoPrognóstico

Câncer de vesícula Câncer de vesícula biliarbiliar

PrognósticoPrognóstico

The anatomic triangle in which approximately 90% of gastrinomas are found. (From Stabile BE, Morrow DJ, Passaro E Jr: The gastrinoma triangle: Operative implications. Am J Surg 147:25-31, 1984.)

Bismuth classification of perihilar cholangiocarcinoma by anatomical extent. Type I tumors (upper, left) are confined to the common hepatic duct, and type II tumors (upper, right) involve the bifurcation without involvement of secondary intrahepatic ducts. Type IIIa and IIIb tumors (lower, left) extend into either the right or left secondary intrahepatic ducts, respectively. Type IV tumors (lower, right) involve the secondary intrahepatic ducts on both sides.

Endoscopic retrograde cholangiogram demonstrating a perihilar cholangiocarcinoma involving secondary intrahepatic branches on the right as well as the common hepatic duct. The left hepatic duct is not visualized.

CAUSES AND RISK FACTORS• Increasing age• Smoking• Chronic pancreatitis• Hereditary pancreatitis• Familial pancreatic cancer• Familial excess of pancreatic cancer (FEPC)RECOMMENDATIONS• Continued health education to avoid tobacco consumption shouldlower the risk of developing pancreatic cancer• Continued health education to avoid excess alcohol consumptionshould lower the risk of developing chronic pancreatitis• All patients with an increased inherited risk of pancreatic cancershould be referred to a specialist center offering specialist clinicaladvice and genetic counseling, and where appropriate genetictesting such as for BRCA2 mutations

TABLE 73.1 HEREDITARY CANCER SYNDROMES AFFECTINGTHE PANCREASSyndrome Gene defect/affectedchromosomeHereditary nonpolyposis colon cancer Defective DNA mismatch(HNPCC) repair enzymesFamilial atypical multiple mole p16melanoma (FAMMM)Familial breast cancer BRCA2Ataxia telangiectasia ATMvon Hippel-Lindau disease VHLHereditary pancreatitis PRSS1Familial pancreatic cancer 4q32–34 ?Li-Fraumeni syndrome p53Cystic fibrosis 7q31Familial adenomatous polyposis (FAP) 5q12–21Peutz-Jeghers syndrome STK11

TABLE 73.2 HISTOLOGICAL VARIANTS OF MALIGNANT TUMORS OF THE EXOCRINE PANCREAS

Histological type Frequency Features

Ductal adenocarcinoma 82% Long-term survival rare

Anaplastic 5% Worse prognosis than ductal

Mucinous cystadenocarcinoma 3% Better prognosis than ductal

Acinar cell 2% Poor prognosis

Mucinous noncystic 2% –

Adenosquamous 2% Poor prognosis

Small cell 1% Extremely poor prognosis

Squamous cell carcinoma <1% More aggressive than ductal

Intraductal papillary-mucinous <1% More favorable prognosis then ductal

Serous cystadenocarcinoma Rare Prognosis similar to ductal

Pancreatoblastoma Rare Childhood tumor

CLINICAL PRESENTATION• Symptoms• Painless jaundice• Weight loss• Back pain• Late onset diabetes mellitus• Acute/chronic pancreatitis• Acute cholangitis• Duodenal obstruction• Deep vein thrombosis• Signs• Jaundice• Hepatomegaly• Palpable gallbladder (Courvoisier’s sign)• Cachexia• Troisier’s sign (Virchow’s node)• Abdominal mass• Ascites

DIFFERENTIAL DIAGNOSIS OF A PANCREATIC MASS• Duodenal carcinoma• Ampullary carcinoma• Cholangiocarcinoma• Neuroendocrine tumor• Endocrine tumor• Chronic pancreatitis• Cystadenoma• Anaplastic cancer• Mucinous cystadenocarcinoma• Acinar cell• Mucinous noncystic• Adenosquamous• Small cell• Squamous cell carcinoma• Intraductal papillary-mucinous• Serous cystadenocarcinoma• Pancreatoblastoma• Metastatic tumor• Tuberculous mass• Lymphoma

DIAGNOSTIC METHODSTransabdominal ultrasoundContrast-enhanced computerized tomography (CE-CT) scanSpiral CT scanMagnetic resonance imaging scan (MRI)Magnetic resonance cholangiopancreatography (MRCP)Positron emission tomography (PET) scanEndoscopic ultrasound (EUS)Endoscopic cholangiopancreatography (ERCP)LaparoscopyLaparoscopic ultrasound