Download - AN V N PANCREAS
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Neoplasmul pancreatic
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Cancerul pancreatic
A patra cauză de cancer la bărbaţi
A cincea cauză de cancer la femei
Incidenţă: 8-13 cazuri/100 000 loc/an
Cel > letal cancer Cea < rată de
supravieţuire (˂ 5% la 5 ani)
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Factori de risc
Factori demografici Vârsta înaintată (după 60 de ani) Sexul (mai frecvent la sexul masculin)
Factori de mediu Fumatul Consumul de alcool Carcinogeni din mediu (amine aromatice, cadmiu)
Condiţii medicale Diabetul zaharat Pancreatita cronică
Istoricul familial
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Morfopatologie
70% pancreas cefalic
20% pancreas corporeal
10% pancreas caudal
Cea mai frecventă tumoră pancreatică: adenocarcinomul ductal
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Tablou clinic
Scădere ponderală caşexie Durere în abdomenul superior dorsal Icter obstructiv Diabet zaharat Tulburări psihice Tromboflebita migratorie (semnul
Trousseau) Manifestările MTS
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Scăderea ponderală
90-100% din bolnavi: > 10% din Gc
Anorexie (selectivă pentru carne) Malabsorbţie
Pentru grăsimi steatoree Pentru proteine edeme
Greţuri, vărsături (invazia stomacului, duodenului, MTS peritoneale)
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Durerea abdominală
75% din localizările cefalice 90% din localizările corporeale/caudale Localizare: epigastru Iradiere: dorso-lombară Caracter: progresivă, cvasipermanentă Factori agravanţi: postprandial, decubit
dorsal Factori amelioranţi: aplecare în faţă,
poziţia şezând
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Icterul obstructiv neoplazic
80% din localizările cefalice Compresia + invazia tumorală a CBP Icter colestatic lent progresiv
Prurit Afebril Urini hipercrome, scaune acolice Semnul COURVOISIER-TERRIER
(colecist destins, palpabil, nedureros)
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Metastaze
Hepatice
Peritoneale
Pulmonare
Osoase
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Cancerul pancreatic cefalic
Icter progresiv + prurit Hepatomegalie Semnul Courvoisier-Terrier Scădere ponderală ± Durere abdominală
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Cancerul pancreatic corporeal
Durere abdominală
Scădere ponderală
Tromboflebita migratorie
± Icter
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Cancerul pancreatic caudal
Durere abdominală
Tromboflebita migratorie
Tulburări de glicoreglare/DZ
Absenţa icterului
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Explorări diagnostice
Explorări hematologice şi biochimice Explorări imagistice Examen morfopatologic
Markeri tumorali Markeri genetici
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Probe de laborator
Sindrom anemic Sindrom inflamator (leucocitoză, VSH↑) Sindrom de colestază (bilirubina↑, FA↑,
GGT↑) Sindrom de hepatocitoliză Amilaza↑, lipaza serică↑
CA 19-9 (sensibilitate ~ 70%, specificitate ~ 90%)
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Explorări imagistice
Ecografia abdominală convenţională Computer tomografia (CT spiral) Rezonanţa magnetică nucleară (MRCP) Colangiopancreatografia endoscopică
retrogradă (ERCP) Ecoendoscopia (EUS) Tomografia cu emisie de pozitroni (PET)
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Ecografia abdominală
Tumori > 2 cm
MTS hepatice
Dilatarea căilor biliare, ductului Wirsung
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Eco
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Eco
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CT
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CT
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Rx
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EUS
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ERCP
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RMN
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Principii terapeutice
Tratamentul tumorilor localizate, potenţial rezecabile
Tratamentul tumorilor avansate nerezecabile
Tratamentul cancerului pancreatic metastatic
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Modalităţi terapeutice
Tratamentul chirurgical
Chimio-radioterapia
Tratamentul paleativ Controlul durerii Tratamentul icterului obstructiv
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Tratamentul tumorilor potenţial rezecabile Tumoră pancreatică fără invazie vasculară în
artera mezenterică superioară, trunchiul celiac, fără MTS la distanţă (10-15%)
Tumori cefalice Procedura Whipple cu păstrarea pilorului
Tumori corporeale/caudale Pancreatectomia totală/caudală extinsă
Chimio-radioterapia adjuvantă (Gemcitabină, 5-fluorouracil)
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Tratamentul cancerului de pancreas local avansat nerezecabil Tumoră pancreatică ce înglobează
artera mezenterică superioară, trunchiul celiac, asocierea cu MTS ganglionare peripancreatice voluminoase
Radio-chimioterapia cu 5-fluorouracil/Gemcitabină
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Tratamentul cancerului pancreatic metastatic
Monochimioterapie cu Gemcitabină
Tratament paleativ
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Tratamentul paleativ
Tratamentul durerii
Tratamentul obstrucţiei biliare şi digestive
Ameliorarea calităţii vieţii
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Controlul durerii
Antalgice uzuale Pentazocină Buprenorfină Opiacee Neuroliza plexului celiac sub control CT
sau EUS Infiltraţia peridurală continua cu Xilină Radioterapia
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Tratamentul obstrucţiei biliare/digestive
Tratament chirurgical Drenaj biliar intern: anastomozarea unui
segment al căilor biliare extrahepatice (colecist sau CBP) la un segment învecinat al tubului digestiv (stomac, duoden, jejun)
Tratament endoscopic Protezarea căii biliare: proteze din plastic,
proteze metalice expandabile
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Neoplasmul pancreatic
CAZ CLINIC
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C. G., 68 de ani, pensionar, mediul urbanMotivele internării
Dureri în epigastru, mezogastru, cu iradiere în hipocondrul drept şi dorsal
Vărsături alimentare şi bilioase, precedate de greaţă
Inapetenţă Scădere ponderală aprox. 8 kg în 3 luni Icter sclerotegumentar asociat cu prurit
progresiv de 10 zile şi urini hipercrome
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AHC
Mama – decedată 82 de ani (AVC)
2 fiice aparent sănătoase
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APP
1962 - apendicectomie
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CVM
Pensionar, fost funcţionar public
Consum ocazional de alcool
Fumător 30 ţigarete/zi de 50 de ani
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Istoric
Debut insidios prin dureri progresive de etaj superior abdominal, cu iradiere dorsală, accentuate postprandial
Inapetenţă scădere ponderală importantă
Icter sclerotegumentar + prurit Medicaţie: alcool mentolat + Silimarină !!! Vechi tuşitor cronic
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Examen obiectiv
Pacient subponderal, afebril T.A. 110/70 mmHg, AV 70/min Tegumente şi mucoase icterice Leziuni de grataj Stetacustic pulmonar: raluri bronşice
bilateral
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Examen obiectiv
Abdomen mobil respirator, sensibil la palpare în epigastru, mezogastru
Hepatomegalie la 5 cm sub r.c., regulată, fermă, nedureroasă
Formaţiune indoloră, elastică palpabilă în hipocondrul drept
Test Hemocult ++
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Examene de laborator
Hb 11,7 g% Ht 33,7% VEM 91,6μ3
CHEM 32,9 g/dl HEM 30,8 pg/cell GA 9940/mmc Trombocite 322 000/mmc VSH 87 mm/1h
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Examene de laborator
Bilirubina T 16,5 mg/dl
D 10,2 mg/dl FA 656 U/l
GGT 332 U/l
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Examene de laborator
ALT 69 U/l
AST 56 U/l
Sideremie 74 μg/dl
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Examene de laborator
PT 5,9 g/dl
Glicemie 92 mg/dl
Colesterol 160 mg/dl
Trigliceride 112 mg/dl
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Examene de laborator
Amilaza serică 203 U/l Amilaza urinară 541 U/l Na 130 mmol/l K 2,9 mmol/l Cl 107 mmol/l RA 29,4 U/l
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EKG – morfologie normală
Rx toracică – hiluri bogat arborizate
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Diagnostic de etapă
Icter obstructiv Sindrom consumptiv Bronşită cronică tabagică Anemie secundară Sindrom inflamator Dezechilibru h – e
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Diagnostic diferenţial
Icter colestatic Neoplasm pancreas cefalic Litiaza coledociană Ampulom vaterian Colangiocarcinom Carcinom duodenal
Sindrom consumptiv Alte neoplazii abdominale (limfom, MTS hepatice,
neoplasm hepatic, gastric, vezică biliară)
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Plan de investigaţiiExplorări imagistice
Ecografia abdominală convenţională Computer tomografia (CT) Colangiografia în rezonanţă magnetică
nucleară (MRCP) Colangiografia endoscopică retrogradă
(ERCP) Ecoendoscopia (EUS) Tomografia cu emisie de pozitroni (PET)
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Plan de investigaţiiMarkeri tumorali
CA 19-9
Antigenul carcinoembrionar (ACE)
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Ecografia abdominală
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Ecografia abdominală
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EDS
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CT
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CA 19-9: 2390 U/ml
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Diagnostic pozitiv
Neoplasm pancreas cefalic
Icter obstructiv secundar
Anemie secundară
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Cum tratăm?
Medical
Chirurgical
Endoscopic
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Ce tratăm?
Tratamentul durerii
Tratamentul icterului
Reechilibrarea hidro-electrolitică
Terapia insufienţei evacuatorii gastrice şi de suport nutriţional
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Controlul durerii
Antialgice uzuale: Tramadol Pentazocină Buprenorfină Opiacee Blocarea cu alcool a plexului celiac Splahnicectomia/ganglionectomia
celiacă
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Tratamentul suportiv
Reechilibrare h-e: S.F., KCl i.v., Ringer
Antisecretorii: Pantoprazol i.v.
Prokinetice: Metoclopramid i.v.
Nutriţie parenterală: S.G., Aminosteril, Intralipid
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Tratamentul icterului
Vitamina K i.v.
Antibioterapie i.v.: Ampicilină + Gentamicină
Tratament chirurgical paleativ Gastro-jejunoanastomoză + colecisto-
jejunoanastomoză
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