Câncer de pâncreas e vias biliares

 Incidência  Mortalidade  5ª causa de morte por câncer na América do Norte no ano de 2000 Câncer pancreático Epidemiologia

 Pancreatite crônica  Diabetes Melitus  Anomalias na junção dos ductos biliopancreáticos  Hábito de fumar  Consumo de café Câncer pancreático Grupos de risco

 Clínico  Icterícia – 50%  Dor lombar  Perda de peso  Diminuição do apetite Câncer pancreático Diagnóstico

 Clínico  Sinal de curvoisier-terrier Câncer pancreático Diagnóstico

 Laboratorial  CA 19-9  Diagnóstico  Prognóstico  Monitoração Câncer pancreático Diagnóstico

 Imagenológico  US abdome superior  TC abdome superior Câncer pancreático Diagnóstico

 Tomográficos  Artéria mesentérica superior livre  Veia mesentérica superior livre  Tronco celíaco livre Câncer pancreático Critérios de ressecabilidade

 Intra hepáticas  Extra hepáticas  Vesícula biliar Vias biliares

 Imagenológico  US abdome superior  TC abdome superior  Endoscopia digestiva alta com duodenoscopia Tumores peri-ampolares Diagnóstico

TNMTNM Câncer pancreático Estadiamento

 Cirúrgico  Operação de Whipple  Linfadenectomia  Radioterápico  Quimioterápico Câncer pancreático Tratamento

 Incidência  Mortalidade Câncer de vesícula biliar Epidemiologia

 Suspeito  Inaparente Câncer de vesícula biliar Diagnóstico

 Cirúrgico  Colecistectomia simples  Colecistectomia com:  Segmentectomia hepática IV e V  Linfadenectomia regional Câncer de vesícula biliar Tratamento

Câncer pancreático Prognóstico

Câncer de vesícula biliar Prognóstico

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 should lower the risk of developing pancreatic cancer Continued health education to avoid excess alcohol consumption should lower the risk of developing chronic pancreatitis All patients with an increased inherited risk of pancreatic cancer should be referred to a specialist center offering specialist clinical advice and genetic counseling, and where appropriate genetic testing such as for BRCA2 mutations

TABLE 73.1 HEREDITARY CANCER SYNDROMES AFFECTING THE PANCREAS Syndrome Gene defect/affected chromosome Hereditary nonpolyposis colon cancer Defective DNA mismatch (HNPCC) repair enzymes Familial atypical multiple mole p16 melanoma (FAMMM) Familial breast cancer BRCA2 Ataxia telangiectasia ATM von Hippel-Lindau disease VHL Hereditary pancreatitis PRSS1 Familial pancreatic cancer 4q32–34 ? Li-Fraumeni syndrome p53 Cystic fibrosis 7q31 Familial adenomatous polyposis (FAP) 5q12–21 Peutz-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 METHODS Transabdominal ultrasound Contrast-enhanced computerized tomography (CE-CT) scan Spiral CT scan Magnetic resonance imaging scan (MRI) Magnetic resonance cholangiopancreatography (MRCP) Positron emission tomography (PET) scan Endoscopic ultrasound (EUS) Endoscopic cholangiopancreatography (ERCP) Laparoscopy Laparoscopic ultrasound