Pancreatic tumor is a type of tumor of the pancreas that
can both exocrine and endocrine pancreatic tissue, as well as its support
network that can occur benign or malignant. Mostly for pancreatic exocrine
tumor types derived from duct cells and cell asiner, 90% of them are malignant
tumors of pancreatic ductal adenocarcinoma which is a primary neoplasm in which
the frequency is 80% of all pancreatic malignancies and 90% of the tumor
epithelial malignancies.
Most of caput pancreatic carcinoma occurs in the pancreas
(75%), the rest are found in the corpus (15%). Pancreatic cancer is very
difficult to diagnose at an early stage, asymptomatic symptoms, slow the rapid
growth of so-called silent killer. Pancreatic carcinoma is an aggressive Janis
tend to obstruct the adjacent ducts, blood vessels and adjacent structures such
as perivascular, perineural, and lymphatic dissemination. Metastasis also
extends to the lymph nodes, liver and peritoneum. Median survival is approximately
four months after being diagnosed with a poor prognosis.
Pancreatic carcinoma incidence of 7.6 per 100 thousand per
year in Western Europe, approximately 2.5% of all new cases are diagnosed
tumors and 5% of all cancers. Pancreatic cancer is the number four cause of
death in America and eighth in the world. The majority coming from the duct
(85%) in which men than women of 1.5: 1 with ages between 60-70 years. The
American Cancer Society estimates that in 2010 approximately 43 140 new cases of
pancreatic cancer (21 370 men and 21 770 women) diagnosed and 36,800 people
died of pancreatic cancer. International incidents in the world ranks 13th and
ranks 8th cause of death. Other countries 8-12 cases per 100,000 people per
year. Pancreatic carcinoma incidence of 7.6 per 100,000 per year in Western
Europe, approximately 2.5% of all newly diagnosed cases of tumors and 5% of all
cancers. More common in males (1.5: 1) with ages between 60-70 years.
The actual cause of pancreatic cancer is still unclear.
Epidemiologic studies showed no association with pancreatic cancer several
exogenous factors (environmental) and endogenous factors of the patient. Cancer
etiology exogenous factors eg smoking, high-fat diet, alcohol, coffee, and
industrial carcinogens. Endogenous factors such as patient age, disease of the
pancreas (chronic pancreatitis and diabetes mellitus) and genetic mutations.
Cancer incidence increases in the elderly.
Pancreatic cancer is nearly 90% comes from the duct, where
75% of the classical form of ductal adenocarcinoma cells that produce mucin.
Most cases (± 70%) the location of cancer in the head of the pancreas, 15- 20%
by weight and 10% on the tail. In the area of pancreatic head carcinoma can
cause obstruction of the bile duct and pancreatic duct distal areas, this can
lead to clinical manifestations in the form of jaundice.
Generally, the tumor extends to retroperitonel backward
pancreas, coating and attached to the blood vessels. Microscopic there is
infiltration in adipose tissue peripankreas, lymphatics, and perineural. In
later stages, pancreatic head cancer often metastasizes to the duodenum,
stomach, peritoneum, liver and gall bladder.
Pancreatic carcinoma is believed to originate from ductal
cells in which a series of genetic mutations had occurred in the protooncogene
and tumor suppressor genes. Mutations in the K-ras oncogene is believed to be
the initial event in tumor progression and there are more than 90% of tumors.
The loss of function of several tumor suppressor genes (p16, p53, DCC, APC, and
DPC4) is found in 40-60% of tumors. K-ras mutation detection of pancreatic
fluid obtained at endoscopic retrograde cholangiopancreatography has been used
in clinical studies to diagnose pancreatic cancer.
In most cases, the tumor is already large (5-6 cm) and or
has occurred infiltration and attached to the surrounding tissue, so it can not
be in the resection, the tumor can be resected while measuring 2.5-3.5 cm.
The early symptoms of pancreatic cancer are not specific
and vague so often diagnosed late, as a result of disease becomes advanced,
difficult handling and high mortality rates. The initial symptoms may include
the full flavor, bloating in the pit of the stomach, anorexia, nausea,
vomiting, diarrhea and weakness. This complaint is not typical, because it can
be found also in pancreatitis and other intra-abdominal tumor. Initial
complaint is usually more than 2 months before the diagnosis of cancer.
Early clinical symptoms began to
look at the mass originating from the pancreatic head with a diameter smaller
than 2-3 cm at the time of diagnosis, the body and tail of 5-7 cm diameter.
Obstruction jaundice, with a flow passage or dark urine, and pale feces is a
clinical picture that often occurs in pancreatic head carcinoma, usually progressive,
pruritus disturbing, gallbladder usually palpabel, in patients with the
obstruktive jaundice, associated with pancreatic cancer. Weight loss varies,
can be up to about 44 kg, due to the inadequate intake and malabsorption and
decreased function of the liver. Abdominal pain is approximately 70% at the
time of diagnosis, infiltration of neoplasms can cause back pain indicates a
poor prognosis. Diabetes mellitus or glucose intolerance disorder found in one
third of patients. There are steatore and fat absorption failure causes
coagulopathy.
Clinical signs are very dependent
on the location of the tumor and the expansion or stage of cancer. Patients are
generally undernourished, anemic, jaundice, palpable solid tumor mass in the
epigastric, difficult to move because of the location of the tumor in the
retroperitoneum. Can be found jaundice and a palpable mass in the gall bladder
in patients with suspected obstructive jaundice in many neoplastic duct
(Courvoisier Sign) caused by pancreatic cancer, was found in half of the cases,
hepatomegaly, splenomegaly, ascites. Other disorders are nodules periumbilikus
(Sister Mary Joseph's nodule), venous thrombosis and migratory thrombophlebitis
(Trousseau's syndrome), gastrointestinal bleeding and edema of the legs.
Diagnosis of pancreatic cancer with
clinical symptoms, laboratory such as the increase in serum bilirubin and
transaminase, coupled with supporting a diagnosis of tumor markers such as CEA
(Carcinoembrionic antigen) and Ca 19-9, gastroduodenografi, ultrasound,
CT-Scan, pancreatic scintigraphy, MRI and ERCP, endoscopic ultrasonography ,
angiography, PET, surgical and biopsy.
In patients with jaundice, because
there are obstructive nature to do urine, blood and faeces. Ultrasound can
detect dilatation of the biliary tree, showing mass lesions of the pancreas or
liver metastasis. MRCP is better because it is less invasive than ERCP and can
show bile duct and pancreatic duct, and determine the need for therapeutic
intervention. A discovery that pancreatic cancer is often in double duct sign.
Where both the pancreatic duct and the common bile duct narrowing and bypassed
the tumor. Tumor markers such as CA 19-9 is less sensitive and specific but can
be used for follow-up of patients treated and followed resection can detect
recurrence.
Transabdominal ultrasonography,
endoscopic and ERCP / MRCP each have a role in the diagnosis of pancreatic
ductal adenocarcinoma. Transbdominal an early ultrasound imaging for the
investigation of patients with pancreatic carcinoma, especially with
non-specific symptoms of abdominal pain or jaundice, high accuracy to
differentiate obstructive from non-obstructive. CT using IV contrast are widely
used for the diagnosis and determine the staging. MRI is an examination that is
higher than a CT scan, but it is expensive. ERCP is still used in some cases
because of its ability to directly visualize the duodenum and the ampulla of
Vater and can be done at once for sampling cytology and as access for stent
insertion.
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