A descriptive approach for interpretation and managent of pancreatic cancer.

1. INTERPRETATION AND MANAGEMENT OF
PANCREATIC CANCER
JAIPUR NATIONAL UNIVERSITY
Project work submitted for partial fulfilment for award of
Bachelor of Pharmacy(B.Pharmacy) degree.
Supervised by:
Mr. Ganesh N. Sharma
Asst. Professor (Pharmacology),
School of Pharmaceutical Science,
Jaipur National University (Raj.)
Submitted by:
Bibin Mathew
B.Pharm (4th year),
Enrollment No: JNU-jpr2009/01508.

2. S.No.
TITLES & SUBTITLES
1.
INTRODUCTION
1.1 Cell Cycle
2.
PANCREATIC CANCER
2.1 Functions of pancreas.
2.2 Epidemiology of pancreatic cancer.
2.3 Types of pancreatic cancer.
3.
INTERPRETATION OF PANCREATIC CANCER
4.
CAUSES OF PANCREATIC CANCER
5.
SIGNS AND SYMPTOMS
6.
DIAGNOSIS
6.1 Recent advancement in diagnosis
7.
MANAGEMENT OF PANCREATIC CANCER
7.1 Recent approaches in management of pancreatic cancer
8.
CONCLUSION
9.
REFERENCES

3. 1. INTRODUCTION
 Pancreatic cancer is a malignant neoplasm originating from transformed
cells arising in tissues forming the pancreas. The most common type of
pancreatic cancer, accounting for 95% of these tumors, is adenocarcinoma.
 Tumors of Pancreas
Broadly there are three basic types:
 Ductal adenocarcinoma is 90% of pancreatic cancers with a 4%
5-year survival (worst of any cancer).
 Neuroendocrine tumors ( islet-cell tumors).
 Cystic neoplasm account for <1% of pancreatic cancer.

4. 1.1 Cell Cycle
Phases
Events
Gap 0 (G0)
Resting phase
Gap 1 (G1)
Cells increase in size, control
mechanism to ensure that everything is
ready for DNA synthesis.
DNA replication occurs during this
phase.
Synthesis
(S)
Checkpoint
control
mechanism
ensures that everything is ready to
enter the M (mitosis) phase and divide.
Mitosis (M) Cell growth stops at this stage and
cellular energy is focused on the
orderly division into two daughter
cells.
Gap 2 (G2)

5. 2. PANCREATIC CANCER
 Usually, cancer is named after the body part in which it originate thus
pancreatic cancer refers to the erratic growth and proliferation of cells that
originate in the pancreatic tissue.
Fig.no.2 Human Pancreas

6. The pancreas is prismoid in shape and appears triangular with two major regions i.e.
head and tail portion.
The head of the pancreas lays in the duodenal C loop in front of the inferior vena cava
(IVC) and the left renal vein.
The body and tail of the pancreas run obliquely upward to the left in front of the aorta
and left kidney.
The main pancreatic duct (Duct of Wirsung) runs from the tail through the body to the
head of the pancreas where it descends into the lower (inferior) part of the head.
There it joins the duct of the uncinate process coming from left and then the lower part
of the common bile duct to form a common channel (hepatopancreatic ampulla).
This duct runs through the medial duodenal wall and opens on the dome of the major
duodenal papilla.

7. 2.1 Functions of pancreas
Exocrine
Endocrine
Enzyme
Substrate
Product
Amylase
(active)
Starch,
glycogen
Glucose,
maltose.
Trypsinogen,
Trypsin
(active)
Chymotrypsin
(active).
Cleave
peptide
bonds in
amino
acids
Free amino
acids and
dipeptides.
Pancreatic
Triglyceride Mono
lipase (active)
glycerides
fatty acids.
Beta cells
(Insulin)
D-Cells
(Somato
statin)
Alpha Cells
(Glucagon)
Inhibition
Stimulation

8. 2.2 Epidemiology of pancreatic cancer
Pancreatic cancer is currently the fourth leading cause of cancer
death in the western countries, claiming 32,000 lives annually.
The rate of incidence is increasing which means that the disease is
becoming more common and it is also extremely difficult to treat.
Signs and symptoms of the disease seldom appear until more
advanced stages of cancer.
By the time symptoms appears, cancer cells are likely to have
metastasized to other parts of the body.
While currently pancreatic cancer can be removed by surgery
followed by chemotherapy.

9. 2.3 Types of Pancreatic Cancer
• Pancreatic cancer has been classified into two classes viz. exocrine and
endocrine pancreatic cancer. The endocrine and exocrine pancreatic
carcinomas are further classified into various subclasses.
Fig.no.3 Passaro’s triangle. Typical location of a Gastrinoma

10. Subclasses of endocrine pancreatic cancer
Gastrinoma (Zollinger- • Gastrinomas overproduce gastrin. Most
are malignant or have the ability to
Ellison Syndrome)
become malignant.
Glucagonoma
Insulinoma
Nonfunctional Islet
Cell Tumor (NICT)
• Glucagonomas overproduce glucagon.
They are usually large, often metastasize
and about 70% are malignant.
• Insulinomas overproduce insulin. They
are the most common pancreatic
neuroendocrine tumors.
• Nonfunctional islet cell tumors are usually
malignant. They are hard to detect.

11. Somatostatinoma
• Somatostatinomas overproduce
somatostatin. They can occur anywhere in
the pancreas and in the duodenum.
• VIPomas overproduce vasoactive
Vasoactive Intestinal
intestinal peptide (VIP). These tumors are
Peptide-ReleasingTumor usually located in the body and tail of the
pancreas.

12. Various subclasses of exocrine pancreatic cancer
Acinar Cell Carcinoma
• Rare form of pancreatic cancer that may
cause excessive production of pancreatic
lipase, the enzyme secreted to digest fats.
Adenocarcinoma
• Adenocarcinoma accounts for about 90%
of all pancreatic cancers and it begins in
cells lining the pancreatic duct.
Adenosquamous
Carcinoma
• Adenosquamous carcinoma is similar to
adenocarcinoma in that it forms glands
but it flattens as it grows.
Intraductal PapillaryMucinous Neoplasm
• Grows from the main pancreatic duct or
from side branches. The tumor appear as
a finger-like projection into the duct.

13. Mucinous
Cystadenocarcinoma
Pancreatoblastoma
• Mucinous cystadenocarcinoma is a rare,
malignant, spongy, cystic tumor. The
cyst is filled with a thick fluid called
mucin.
• Pancreatoblastoma is a rare form of
pancreatic cancer found in children
under the age of 10. It is often called
“pancreatic cancer of infancy.”

14. 3. INTERPRETATION OF PANCREATIC CANCER
 There are several stages involved in pancreatic cancer, and two models for
accurately describing them are TNM and Stage models
1. TNM Model
In the Tumor, Node, Metastasis (TNM) system, tumor size, lymph node
health and metastasis activity are measured separately, each with its own
number scale.
2. STAGE Model
The second model for pancreatic cancer involves 4 numbered stages, as
follows:
 Stage1
 Stage2
 Stage3
 Stage 4

15. TNM MODEL
TUMOR
• T1 :Tumor is less
than 2cm across in
any direction.
• T2 :Tumor is larger
than 2cm across.
• T3 : Tumor has
started to grow
into the tissues,
duodenum and
bile duct.
• T4: Tumor has
grown into spleen,
large intestine and
major blood vessel.
NODE
• N0 : There are no
lymph nodes
containing cancer.
• N1 : Lymph nodes
containing cancer
and so the tumor
has likely
metastasized
beyond the
pancreas.
METASTASIS
• M 0 : The tumor
has not spread.
• M1 The tumor has
spread.

16. STAGE MODEL
Stages
TNM
Equivalent
Description
Stage 1
1 or 2,0,0
There has been not spread and is relatively
small. Tumor has not progressed outside
pancreas.
Stage 2
3,0,0
Tumor has grown into nearby tissues and
perhaps the duodenum. Lymph nodes are not
affected.
Stage 3
2 or 3,1,0
Tumor may be quite large and has spread to
the lymph node system.
Stage 4
4A
4,2,0
Tumor has grown into nearby organs
including the spleen and/or stomach, as well
as blood vessels.
4B
1,2,3 or 4,1,1
Tumor has spread to other organs such as the
liver or lungs.

17. 4. CAUSES OF PANCREATIC CANCER
5 Major causes:
Pancreatic cancer

18. 5. SIGNS AND SYMPTOMS
Fig. No.4 Upper abdominal pain that may extend to middle or
upper back.
Fig.No.5 Weight loss due to malignant cancer cells tendency
to deprive healthy cells of nutrients.
Fig.No.6 Jaundice leads to yellowing of skin and eyes.
Fig.No.7 Nausea and vomiting can occur during later stages, if
a pancreatic tumor has grown sufficiently larger
Fig. No. 8 Due to Zollinger Ellison syndrome stomach ulcers
can also happen.

19. 6. DIAGNOSIS
Following methods are used for diagnosis of pancreatic
cancer:
1.Ultrasound of the abdomen.
2.Endoscopic Ultrasonography (EUS).
3.Endoscopic Retrograde Cholangiopancreatography (ERCP).
4.Computed Tomography (CT).
5.Carbon nanotubes.

20. 7. MANAGEMENT OF PANCREATIC CANCER
A number of approaches can be made for the management of pancreatic
cancer which are as follows:
1.Surgery
Fig.no.9 Whipple procedure for pancreatic cancer
surgery.

21. 2. Radiation Therapy
 Radiation therapy ( radiotherapy, x-ray therapy, or irradiation) is the use of a
beam of energy (called ionizing radiation) to kill cancer cells and shrink
tumors.
 Radiation therapy injures or destroys cells in the area being treated (the
“target tissue”) by damaging their genetic material (DNA), making it
impossible for these cells to continue to grow and divide.
 Major side effect is radiation damages both cancer cells and normal cells,
most normal cells can recover from the effects of radiation and function
properly.
 The goal of radiation therapy is to damage as many cancer cells as possible,
while limiting harm to nearby healthy tissue.

22. 3. Chemotherapy
S.no
1.
Chemotherapy
For exocrine pancreatic cancer
Drugs
Gemcitabine, 5Floro
uracil.
2.
Target therapy in exocrine
Erlotinib,
Erlotinib+Gem.
3.
For endocrine pancreatic cancer
Doxorubicin,
Streptozocin
4.
Target therapy for endocrine
Sunitinib , Everolimus
5.
Other drugs for neuroendocrine
Octreotide,Paseriotide
6.
For Zollinger Ellison Syndrome
Proton Pump Inhibitors
7.
For Insulinomas( before surgery)
Diazoxide

23. Gemcitabine: A boon for pancreatic cancer
Fig.no.10 Gemcitabine mechanism

24. 7.1 Recent approaches in management of pancreatic cancer:
Gene Therapy
• Introduction of functional genetic
material into target cells to replace or
supplement defective genes or modify
target cells.
Oncogenes
Inactivation
• Mutations in KRAS are found in more
than 90% of patient . Its inactivation using
suitable vectors is a novel approach.
Immune
enhancement
• Autologous natural killer (NK) cell and activated
T lymphocyte based immunotherapy termed as
autologous immune enhancement therapy.
Enzyme therapy
• Enzymes which are generally given in this
therapy are lipase, protease and amylase.

25. 8. CONCLUSION
 Pancreatic cancer i.e. mainly adenocarcinoma is the major cause of death
associated with pancreatic cancer. Apart from familial disorders the minor
risk factors also cannot be ignored as smoking causes 40% of pancreatic
cancer.
 Due to its poor prognosis mortality rate with pancreatic cancer is high so
the newly developed cheaper and sensitive diagnostic could create a
breakthrough in determining pancreatic cancer.
 Gemcitabine has proved a boon to pancreatic cancer patient Apart from
chemotherapy, gene therapy, oncogens inactivation and enzyme therapy can
be helpful to patients.
 With advances in screening, diagnosis, and treatment, the death rate for
pancreatic cancer has declined. Research is ongoing to develop even more
effective screening and treatment programs.

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30. THANK YOU