Resección vascular mayor por adenocarcinoma pancreático ductal: reporte del primer caso registrado en Paraguay / Major vascular resection for pancreatic ductal adenocarcinoma: case report, of first case reported in Paraguay

El adenocarcinoma pancreático ductal (APD) es la cuarta causa de muerte por cáncer y se proyecta que para el 2030 ocupe el segundo lugar. El pronóstico es sombrío, siendo la sobrevida menor a 9% en 5 años. Se consideró durante mucho tiempo a la resección quirúrgica como el único tratamiento curativo, sin embargo, sólo el 15 a 20% de los pacientes pueden ser beneficiados con la misma. La clasificación pre terapéutica más utilizada es la del National Comprehensive Cáncer Network (NCCN), basada en la relación del tumor con estructuras vasculares, clasificándolos en tumores "resecables", de resección límite "Borderlines" y "localmente avanzados". Se presenta el primer caso registrado en Paraguay de APD con infiltración de la Vena Mesentérica Superior (VMS) tratado con duodenopancreatectomía cefálica (DPC) asociada a resección vascular mayor.

Pancreatic ductal adenocarcinoma (PDA) is the fourth leading cause of cancer death and is projected to rank second by 2030. The prognosis is bleak, with survival being less than 9% in 5 years. For a long time, surgical resection was considered the only curative treatment, however, only 15 to 20% of patients can benefit from it. The most widely used pre-therapeutic classification is that of the National Comprehensive Cancer Network (NCCN), based on the relationship of the tumor with vascular structures, classifying them into "resectable", "borderline" and "locally advanced" tumors. We present the first registered case in Paraguay of PDA with infiltration of the Superior Mesenteric Vein (SMV) treated with cephalic duodenopancreatectomy (CPD) associated with major vascular resection.

Cáncer de páncreas: alteraciones genéticas, cambios morfológicos y sus implicaciones terapéuticas / Pancreas cancer: genetic alterations, morphological changes and its therapeutic implications

Resumen El cáncer de páncreas es una enfermedad mortal, principalmente porque se descubre muy tarde y es muy resistente a la quimioterapia y radioterapia. El tipo más común de cáncer de páncreas (más del 90%) se desarrolla a partir de las células exocrinas del páncreas y se denomina adenocarcinoma ductal pancreático (ACDP). Se han reconocido tres lesiones precursoras de cáncer de páncreas ductal: neoplasia intraepitelial pancreática (PanIN), neoplasia papilar-mucinosa intraductal (NPMI) y neoplasia quística mucinosa (NCM). Uno de los primeros eventos genéticos implicados en la patogénesis de ACDP es una mutación en el punto de activación en el oncogén KRAS, una mutación conductora oncogénica que se encuentra en más del 90% de todos los cánceres de páncreas. Además, se ha informado que hasta un 10% de los cánceres de páncreas están asociados con el historial familiar. Aunque la causa es multifactorial, el tabaquismo y la historia familiar son dominantes. Existe heterogeneidad morfológica en muchos cánceres humanos, pero parece ser un hallazgo particularmente común en ACDP. La cirugía solo es posible en 15-20% de los casos: tumores confinados al páncreas con posible afectación ganglionar local no muy extensa y que no produce afectación vascular o está limitada.

Abstract Pancreatic cancer is a deadly disease, mainly because it is generally discovered very late and it is very resistant to chemotherapy and radiation therapy. The most common type of pancreatic cancer (over 90%) develops from the exocrine cells of the pancreas and is named pancreatic ductal adenocarcinoma (PDAC). Three precursor lesions of ductal pancreatic cancer have been recognized: pancreatic intraepithelial neoplasia (PanIN), intraductal papillary-mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN). One of the earliest genetic events involved in PDAC pathogenesis is an activating point mutation in the KRAS oncogene, an oncogenic driver mutation found in more than 90% of all pancreatic cancer. In addition, it has been reported that up to 10% of pancreatic cancer is associated with family history. Although the cause is multifactorial, cigarette smoking and family history are dominant. Morphological heterogeneity exists in many human cancers, but seems to be a particularly common finding in PDAC. Surgery is only possible in 15-20% of cases: tumors confined to the pancreas with possible local nodal involvement not very extensive and that do not produce vascular involvement or is limited.

Adenocarcinoma de pâncreas / Pancreatic adenocarcinoma

Introdução: Este artigo revisa o conhecimento atual do adenocarcinoma pancreático, dissertando sobre a definição, a sintomatologia e os processos diagnóstico, terapêutico e prognóstico. Métodos: Revisão bibliográfica de artigos científicos, selecionados nas bases Medline e PubMed entre março e maio de 2018, e em sites epidemiológicos sobre neoplasias pancreáticas. Resultados: A doença maligna do pâncreas é uma das neoplasias mais letais na atualidade, uma vez que sua detecção normalmente ocorre em estágios avançados da doença, impossibilitando a ressecção cirúrgica, que é a única opção potencialmente curativa disponível. A maior parte dos casos, entretanto, não é candidata a cirurgia por presença de metástases à distância ou por comprometimento vascular local, notadamente dos vasos mesentéricos. Conclusão: O adenocarcinoma ductal pancreático é uma patologia incomum, mas que merece atenção por sua alta agressividade e prognóstico reservado, com baixos índices de cura e de sobrevida, situação que se mantém inalterada ao longo das últimas décadas.

Introduction: This article reviews the current knowledge about pancreatic adenocarcinoma, discussing definition, symptomatology and diagnostic, as well as therapeutic and prognostic processes. Methods: Bibliographic review of scientific articles, selected from Medline and PubMed databases between March and May 2018, and in epidemiological sites on pancreatic neoplasms. Results: Malignant disease of the pancreas is one of the most lethal neoplasms today, since its detection usually occurs in advanced stages of the disease, making surgical resection impossible, which is the only potentially curative option available. Most cases, however, are not candidates for surgery due to presence of distant metastases or local vascular impairment, notably mesenteric vessels. Conclusion: Pancreatic ductal adenocarcinoma is an uncommon pathology, but it deserves attention because of its high aggressiveness and reserved prognosis, with low rates of cure and survival, a situation that has remained unchanged over the last decades.