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Historia Natural Del Cáncer De Páncreas En El Departamento De Salud De Elda”

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Historia Natural Del Cáncer De Páncreas En El Departamento De Salud De Elda” UNIVERSIDAD MIGUEL HERNÁNDEZ “Historia Natural del Cáncer de Páncreas en el Departamento de Salud de Elda” Departamento de Medicina Clínica TESIS DOCTORAL Sonia Alonso Hernández Junio de 2017 1 D. Javier Fernández Sánchez, Director del Departamento de Medicina Clínica de la Universidad Miguel Hernández AUTORIZA: La presentación y defensa como Tesis Doctoral del trabajo “Historia Natural del Cáncer de páncreas en el departamento de Salud del Elda” presentado por Dña. Sonia Alonso Hernández bajo la dirección del Dr. Rafael Durán García y del Dr. Vicente Francisco Gil Guillén. Lo que firmo en San Juan de Alicante a 4 de Julio de 2017 Prof. D. Javier Fernández Sánchez Director Dpto. Medicina Clínica DEPARTAMENTO DE MEDICINA CLINICA Campus de San Juan. Ctra. de Valencia (N·332), Km. 87 03550 San Juan de Alicante Telf.: 96 5919449 – Fax: 96 5919450 c.electrónico: [email protected] 2 Don VICENTE FRANCISCO GIL GUILLÉN y Don RAFAEL DURÁN GARCÍA como Directores de la Tesis Doctoral CERTIFICAN Que el trabajo “Historia Natural del Cáncer de Páncreas en el Departamento de Salud de Elda” realizado por Dña. Sonia Alonso Hernández ha sido llevado a cabo bajo nuestra dirección y se encuentra en condiciones de ser leído y defendido como Tesis Doctoral en la Universidad Miguel Hernández. Lo que firmamos para los oportunos efectos en San Juan de Alicante a 29 de Junio de 2017 Fdo. Dr. D. Vicente Francisco Gil Guillén Director Tesis Doctoral Fdo. Dr. D. Rafael Durán García Director Tesis Doctoral 3 UNIVERSIDAD MIGUEL HERNÁNDEZ FACULTAD DE MEDICINA Departamento de Medicina Clínica HISTORIA NATURAL DEL CÁNCER DE PÁNCREAS EN EL DEPARTAMENTO DE SALUD DE ELDA. TESIS DOCTORAL Presentada por: Sonia Alonso Hernández Dirigida por: Dr. Rafael Durán García y Dr. Vicente Francisco Gil Guillén Alicante, Junio de 2017 4 Agradecimientos - Mi primer agradecimiento es para mis dos directores de tesis, El Dr. Vicente Gil Guillen, profesor del Departamento de Medicina Clínica de la Universidad Miguel Hernández, gracias por acceder a co-dirigir la tesis y por tu orientación en todo momento. Al Dr. Rafael Duran García, jefe del Servicio de Anatomía Patológica del Hospital General Universitario de Elda, gracias por todos tus esfuerzos e impulsos para que no dejara de escribir la tesis, a tu apoyo como director y sobre todo gracias por ser un buen jefe y un mejor compañero. - Al Dr. José Antonio Quesada, matemático de la Universidad Miguel Hernández de Elche, gracias por tu gran trabajo y ayuda en el procesamiento estadístico de los datos. - Gracias al Prof. Dr. Miguel Ángel Martorell Cebollada. Mi primer maestro en la Anatomía Patológica. Gracias por todo lo que me enseñaste durante mi formación, que me ha hecho llegar hasta estas líneas de mi tesis. - A todos los adjuntos del Servicio de Anatomía Patológica del Hospital General Universitario de Valencia, que me enseñaron mucho más que conocimiento científico. - A mis compañeras de residencia, Beatriz, Nuria y Fernanda. Gracias por vuestros consejos en mis primeros pasos como futura patóloga, pero sobre todo gracias por vuestra amistad incondicional. - A mis compañeros del Hospital Dr. Peset de Valencia, el Dr. Vicente Torres, El Dr. Francisco García, la Dra. Marien Martí y Pepe técnico y enfermero. Además de buenos compañeros sois mejores amigos. 5 - A todos los compañeros del Servicio de Anatomía Patológica del Hospital General de Elda, técnicos, administrativos, celador y facultativos, que durante estos últimos nueve años me habéis apoyado en todo a nivel profesional y personal. Sin vosotros el trabajo del día a día no sería lo mismo. - A mi familia. Mis padres por haber sido mi guía durante mis primeros años y después mi referencia por ser como son. Me enseñaron a ser humilde, a compartir y a conseguir las cosas con mi esfuerzo. Gracias por ser mi apoyo incondicional. Mi marido por estar siempre a mi lado y animarme para continuar hacia delante, te quiero. Mis dos hijos, Aitana y Mario que cada día me enseñan cosas nuevas y me han hecho ver que la vida está llena de pequeños momentos inolvidables, que no hay que perderse. “La verdadera ciencia enseña, sobre todo, a dudar y a ser ignorante”. Miguel de Unamuno. “Estoy agradecido a todos los que me dijeron que no. Es por ello que lo estoy haciendo por mi mismo”. Albert Einstein. 6 ÍNDICE…………………………………………….. 7 Índice ÍNDICE……………………………………………………………………….….pag. 7 ÍNDICE DE ABREVIATURAS…………………………………………...pag. 13 INTRODUCCIÓN…………………………………………………………....pag. 16 1. SITUACIÓN Y TENDENCIAS DEL CÁNCER EN EL MUNDO…………....pag. 17 1.1 Situación del Cáncer en EEUU…………………………................................pag. 19 1.2 Situación del Cáncer en Europa………………………………….…………..pag. 22 1.3 Situación del Cáncer en España……………………………..........................pag. 23 1.4 Previsión del Cáncer para el 2030…………………………………………...pag. 24 2. CÁNCER DE PÁNCREAS, INTRODUCCIÓN, CARGA Y TENDENCIA….pag. 27 3. ANATOMÍA Y FISIOLOGÍA DEL PÁNCREAS……………………………. pag. 31 4. CARACTERÍSTICAS PRINCIPALES DE LOS TUMORES PANCREÁTICOS…... …………………………………………………………………………………..…pag. 34 5. TUMORES DEL PÁNCREAS EXOCRINO…………………………….……..pag. 36 5.1 Clasificación Histológica………………………………………………….…pag. 36 5.2 Características Principales de los diferentes tipos histológicos……………....pag. 38 a) Adenocarcinoma Ductal…………………………………………………….pag. 38 b) Neoplasia Quística Serosa…………………………………………………..pag. 38 c) Neoplasia Quística Mucinosa……………………………………………….pag. 40 d) Neoplasia Mucinosa Papilar Intraductal…………………………………….pag. 43 e) Carcinoma de Células Acinares…………………………………………......pag. 44 f) Neoplasia Sólida Pseudopapilar……………………………………………..pag. 45 g) Pancreatoblastoma……………………………………………………...…..pag. 46 5.3 Causas y Factores de Riesgo del Cáncer de Páncreas…………………….....pag. 47 5.3.1 Factores de Riesgo no Hereditario……………………………………….pag. 48 a) Pancreatitis Crónica………………………………………………………pag. 48 b) Diabetes Mellitus……………………………………………………..….pag. 48 c) Factores Medioambientales y estilos de vida……………………………..pag 48 5.3.2 Factores de Riesgo de carácter Hereditario…………………….………..pag. 50 a) Síndromes de predisposición Genética asociados a Cáncer de Páncreas...pag. 50 b) Cáncer Pancreático Familiar……………………………………………..pag. 51 8 Índice c) Otros…………………………………………………………………...…pag. 51 5.3.3 Bases Genéticas del Cáncer de Páncreas………………………………...pag. 52 a) Activación Mutacional de Oncogenes……………………………………pag. 52 b) Inactivación de Genes Supresores Tumorales…………………………...pag. 52 5.4 Diagnóstico de los Tumores del Páncreas Exocrino………………………....pag. 53 5.4.1 Datos clínicos, Signos y Síntomas……………………………………….pag. 53 5.4.2 Técnicas de Imagen……………………………………………...………pag. 54 a) Ecografía Abdominal……………………………………………………..pag. 54 b) Ecografía Endoscópica…………………………………………………...pag. 54 c) Tomografía Computerizada Multicorte…………………………………..pag. 54 d) Colangiopancretografía Endoscópica Retrógrada………………………..pag. 55 e) Gammagrafía de Receptores de Somatostatina “Octreoscan”…………....pag. 55 f) Tomografía por Emisión de Positrones…………………………………...pag. 55 g) Resonancia Nuclear Magnética…………………………………………..pag. 56 5.4.3 Estudio Histológico, biopsia y/o citología……………………………….pag. 56 a) Biopsia o PAAF Percutánea……………………………………………...pag. 56 b) Biopsia o PAAF endoscópica……………………………………………pag. 56 c) Biopsia Quirúrgica……………………………………………….………pag. 56 5.4.4 Marcadores Tumorales Séricos………………………………………….pag. 57 5.4.5 Estudio Inmunohistoquímico………………………………………….…pag. 57 5.5 Estadio del Cáncer de Páncreas…………………………………………..….pag. 58 5.5.1 Clasificación TNM 7ª Edición, 2010 AJCC/ UICC…………………..…pag. 59 5.5.2 Nueva Clasificación TNM 8ª Edición 2017 AJCC/UICC……………….pag. 63 5.6 Tratamiento del Cáncer de Páncreas…………………………………………pag. 65 5.6.1 Tratamiento Quirúrgico………………………………………………….pag. 65 5.6.2 Tratamiento Adyuvante……………………………………………….…pag. 66 5.6.3 Tratamiento Sistémico…………………………………………………...pag. 68 6. TUMORES DEL PÁNCREAS EXOCRINO…………………………………...pag. 70 6.1 Introducción, Incidencia y Clasificación Clínica………….………………...pag. 70 6.2 Histología……………………………………………………………………pag. 71 9 Índice 6.3 Clasificación y Estadiaje de los Tumores Neuroendocrinos Pancreáticos…..pag. 72 6.3.1 Clasificación de la OMS 2010……………………………………………pag. 72 6.3.2 Nueva Clasificación de la OMS 2017………………………….………..pag. 73 6.3.3 Clasificación TNM de la AJCC/ENETs………………………………….pag. 74 6.4 Diagnóstico de los Tumores Neuroendocrinos Pancreáticos……………..…pag. 76 6.4.1 Clínica………………………..………………………………………….pag. 76 6.4.2 Técnicas de Imagen……………………………………………………...pag. 76 6.4.3 Marcadores Tumorales Serológicos…………………………………..…pag. 77 6.4.4 Estudio Histológico…………………………………………………...…pag. 77 6.5 Tratamiento de los Tumores Neuroendocrinos Pancreáticos………………..pag. 77 6.5.1 Tratamiento Quirúrgico……………………………………………….…pag. 78 6.5.2 Tratamiento de la Enfermedad Localmente Avanzada o Metastásica..….pag. 78 6.5.3 Tratamiento Médico Sistémico…………………………………………..pag. 79 6.6 Pronóstico………………………………………………..………………….pag. 80 JUSTIFICACIÓN DEL ESTUDIO ………………………………………pag. 81 OBJETIVOS DEL ESTUDIO……………………………………………..pag. 83 HIPÓTESIS DEL ESTUDIO………………………………………………pag. 85 MATERIAL Y MÉTODOS………………………………………………..pag. 87 1. TIPO DE ESTUDIO……………………………………………………………pag. 88 2. ÁREA DEL ESTUDIO………………………………………………………….pag. 88 3. BÚSQUEDA Y SELECCIÓN DE LA MUESTRA…………………………….pag. 89 4. DURACIÓN DEL ESTUDIO…………………………………….…………….pag. 91 5. VARIABLES DE LA MUESTRA. BÚSQUEDA Y SELECCIÓN………….…pag. 91 5.1 Edad………………………………………………………………………….pag. 91 5.2 Sexo……………………………………………………………………….....pag. 91 5.3 Localidad………………………………………………………………….…pag. 91 5.4 Historia de Tabaquismo……………………………………………………..pag. 91 5.5 Consumo de Alcohol………………………………………………………...pag.
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