diagnosticul tumorilor solide ale pancreasului exocrin(1)

8/11/2019 Diagnosticul Tumorilor Solide Ale Pancreasului Exocrin(1)

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U.M.F. GR.T. POPA IASI

`

The neoplasia of the digestive

tube: the diagnostic of the solidetumors of the exocrine pancreas

Author: Tibuleac Alexandra


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The neoplasis of the digestive tube arefrequently diagnosed in advanced

stages when the oncological treatmentis hard to approach.The diagnosis ismade sometimes by chance, due to

some other medical conditions.


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One of the most difficult neoplasia ofthe digestive tube to identify is the

solid tumor of the exocrine pancreas,as it is usually diagnosed in advancedstages.

Another issue that interferes with thediagnose of this kind of tumor is thefact that many times it can be

confused with the psedotumoral formof the chronic pancreatitis.


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Chronic pancreatitis- pseudotumoral

form

Chronic pancreatitis is commonly definedas a continuing chronic inflammatoryprocess of the pancreas, characterized byirreversible morphological changes. Thischronic inflammation can lead to chronicabdominal pain and/or impairment ofendocrine and exocrine function of the

pancreas.


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The neoplasia of the exocrine

pancreas

Ductal carcinoma represents 90% of the exocrinetumors i75% of all malignant tumors of pancreas.

Kevin G. Burnand, Anthony E. Young - TheNew AirdsCompanion in Surgical Studies2-nd edition, 1999,pag.962-963;

The fifth cause of mortality through cancer in men(after lung, colon and prostate cancer)

Isselbacher, Fauci, Braunwald, Martin, WilsonHarrisonEdiiaa 14-a,Editura Teora, 2004

The fifth cause of mortality through cancer inwomen( after breast, lung, colon, genital cancer)

Isselbacher, Fauci, Braunwald, Martin, WilsonHarrisonEdiiaa 14-a,Editura Teora, 2004


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Material and method

The study is based on the analyze of

cases from the third hospital ofsurgery, in the period January 2000 December 2004.


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Material and method

798 cases with

pancreatitis affections

91 cases pseudotumoralform

of the chronic pancreatitis

212 cases of neoplasia

of the exocrine pancreas


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Material and method

Demographic parameters

Risk factors

Date clinice

Date paraclinice (de laborator, imagistice,

anatomie patologic)Controale postoperatorii


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Sex distribution of the pseudotumoral

form of the chronic pancreatitis

Women

27%

Men

73%


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Demographic distribution of the pseudotumoral


Rural

areas

40%

Urban

areas

60%


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Age and sex distribution of the pseudotumoral


0

2

4

6

8

10

12

14

80

Women Men


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Bad habits for the patient with the

pseudotumoral form of the chronic pancreatitis

Alcohol

27%

tobacco

8%

Tutun&

Alcool

27%

Denies theuse of

alcohol

38%


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Ponderea antecedentelor personale

patologice n pancreatita cronic

pseudotumoral

8%

5%3%

26%

18%

40%

Ulcer duodenal

Pseudochist

Ulcer duodenal&Hepatita cronica

Pancreatita acuta

Pancreatita acuta&

Pseudochist

Diabet zaharat


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Localizarea durerii n pancreatita

cronicpseudotumoral

Durere in

hipocondrul

stang

7%

Durereabdominala

superioara

25%

Durere

iradiata

posterior

9%

Durere in

hipocondrul

drept

21%

Durereepigastrica

38%


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Simptomele asociate durerii n

pancreatita cronicpseudotumoral

Scadereponderala

29%

Greturi&

Varsaturi

23%

Icter

16%

Scaune acolice

8%

Astenie

24%


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Imagistica in diagnosticul

pancreatitei cronice pseudotumorale

Anul Nr.pacienti ECHO CT IRM ERCP

2000 22 19 3 0 4

2001 5 2 5 0 1

2002 15 13 6 4 0

2003 8 8 3 0 0

2004 13 13 10 2 0

Total 63 5587%

2743%

69,5%

58%


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DISTRIBUIA PE SEXE A

NEOPLASMULUI PANCREASULUI

EXOCRIN

Sex feminin

49%

Sex

masculin51%

In conformitate cu datele prezentate de :

Andren-Sandberg A.Demographics of exocrine pancreatic cancer with special reference to age, sex and time tends, Int J Pancreatol, 1993; 214-6

Backman PL, Barlow L, Andren-Sandberg ADecreasing incidence of exocrine pancreatic cancer in Sweden, Int J Pancreatol 1995;18:289-90.

Bourhis J, Lacaine R, Augusti M, Huguier MProtective effect of estrogen in pancreatic cancer, Lancet, 1987.


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Distribuia demografica

neoplasmului de pancreas exocrin

RURAL

53%

URBAN

47%

Maruchi N, Brian D, Ludwig JCancerof the pancreas in Olmsted County,Minnesota, 1935-1974, Mayo Clin Proc, 1979; 54:245-9.Royall D, Jeejeebhoy KN, Taylor BRNutritionalstatus and function in patients following Whipple procedure compared with controls,J Am Coll Nutr, 1996; 15:73-8.


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Distributia pe grupe de varsta si sex a

pacientilor cu neoplasm de pancreas

exocrin

0

5

10

15

20

25

30

35

40

80

Sex feminin Sex masculinIn conformitate cu :Maruchi N, Brian D, Ludwig JCancerof the pancreas in Olmsted County,Minnesota, 1935-1974, Mayo Clin Proc, 1979; 54:245-9.

Smith PE, Krementz ET, Reid RJAnanalysis of 600 with carcinoma of the pancreas,Surg Gynecol Obstet, 1967, 124:1288-96.Pitt HACurativetreatement for pancreas neoplasms. Standard resection,Surg Clin North Am, 1995; 75:891-904.


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Distribuia factorilor de risc ai

neoplasmului pancreasului exocrin

Alcool

21%

Tutun

5%Neaga

consumul

57%Tutun &

Alcool

17%


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Sediul durerii n neoplasmul de

pancreas exocrin

0

10

20

30

40

50

60

70

Epigastric

Hipocondrustang

Hipocondrudrept

Abdominalsuperior


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Simptome asociate durerii n

neoplasmul de pancreas exocrin

Simptom Nr.Cazuri Procente(%)

Urini hipercrome &

scaune acolice

52 12,35

Greuri & vrsturi 50 11,87

Icter 105 24,94

Prurit 39 9,29

Scdere ponderal 102 24,22

Astenie & inapeten 73 17,33


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The pseudotumoral form of the

chronic pancreatitis

In population studies, males are affectedmore commonly than females (6.7 vs 3.2 per100,000 population).

Rates in males peak at age 45-70 years andthen decline; female rates reach a plateau,which remains stable after age 35 years.

Sex differences with respect to etiology also

exist. Alcohol-induced illness is moreprevalent in males, idiopathic andhyperlipidemic-induced pancreatitis is moreprevalent in females, and equal sex ratios areobserved in chronic pancreatitis associated

with hereditary pancreatitis.


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The neoplasm of the exocrine

pancreas

affects in equal proportions both men andwomen, despite the area from which theybelong (urban/rural);

the angle of incidence is between 60-80 yearsold;

At women the incidence grows aftermenopause (the protective role of estrogen);

The diagnose is late because the primarysymptoms, abdominal pain and jaundice,appear in the advanced stages of the illness;


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The neoplasm of the exocrine

pancreas

At the point of diagnose, 90% of the pacientsare already in the state of ganglionic,lymphatic invasion and/or metastatic;

It can have as a first sign the debut of thediabetului zaharat, after 60 years or more,without obesity and with a fast evolutiontowards the insulin dependence;

the tumore manifests when it has largedimensions, extension in nearby tissues andmetastasis, and it can not be , usually,resected ;


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Neoplasmul de pancreas exocrin

ecographie has its limits: only to 69,42% ofthe pacients the echo investigation helped toidentify the tumorale system;

explorarea intraoperatorie rmne metodacea mai bunde diagnostic, stadializare ideapreciere a rezecabilitii;

ecografia intraoperatoriear trebui sintre n

arsenalul uzual al oricreiinterveniin sferapancreatic. Combinat cu explorareamanualreprezintmetoda cu cea mai mareacurateediagnostic.


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Pancreatita cronic pseudotumoral

vs neoplasmul pancreasului exocrin

diagnosticul diferenial ntre pancreatita

cronic pseudotumoral i neoplasmul de

pancreas exocrin este dificil de realizat chiarsi computer tomografic;

computer tomografia rmne nsa cea mai

important metod imagistic ce poate da

relaii asupra tumorii, raporturilor acesteiacu structurile nvecinate, adenopatiilor,

metastazelor hepatice.


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endoscopia retrograd colangiopancreaticeste metoda golden standard pentrulocalizarea cefalic a tumorilor solidepancreatice cu rsunetasupra cilorbiliare ipancreatice,

rezonan magnetic imagistic are o

contribuia limitat n diagnosticuldiferenialal tumorilor solide pancreatice iarcosturile relativ crescute o fac s nu fieutilizatde primintenie.


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Rezonanamagneticcolangiopancreatografic(MRCP) este o noumetod neinvaziv de diagnostic a

modificrilor ductului pancreatic, biliar i aorganelor adiacente n diferite axe.

Puncia biopsie intraoperatorie, eventualghidat ecografic, poate trana diagnosticulanatomopatologic n prezena unei masetumorale pancreatice, chiar daca este grevatde unele riscuri iaccidente

diagnosticul tumorilor solide ale pancreasului exocrin(1)

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