Pancreatic cancer

Question 1

Define pancreatic cancer.

Answer 1

Malignancy arising form the endocrine or exocrine tissues of the pancreas.

Usually pancreatic ductal adenocarcinoma, (>85%) presenting with painless jaundice and weight loss.

Question 2

What are the risk factors for pancreatic cancer?

Answer 2

Unknown cause

FH (10%) - hereditary syndromes include…

• BRCA2 mutation
• familial atypical multiple mole melanoa (CDKN2A)
• Peutz-Jeghers (STK11/LKB1)
• hereditary pancreatitis (PRSS1)
• MEN
• HNPCC
• FAP
• Gardner
• von Hippel-Lindau syndrome

Question 3

What is the pathophysiology of pancreatic cancer?

• where do most occur
• where does it spread to
• what cell type do most pancreatic cancers affect

Answer 3

• 75% occur in head/neck of the pancreas (periampullary tumour)
• 15-20% occur in the body and 5-10% occur in the tail
• Spread is local and to the liver
• 80% adenocarcinomas, others adenosquamous, mucinous cystadenocarcinomas, or endocrine tumours (insulinomas, gucagonomas, gastrinomas)

Question 4

Name 3 types of pancreatic cancer precursor lesions.

Answer 4

Precursor lesions include

1. pancreatic intraepithelial neoplasia (PanIN)
2. intraductal papillary mucinous neoplasm
3. mucinous cystic neoplasm

Question 5

What is the epidemiology of pancreatic cancer?

Answer 5

• Poor prognosis
• Cancer of old people - peak age 60-80years
• M>F 2:1
• 4th most common cause of cancer-related deaths in UK

Question 6

What is the typical presentation of pancreatic cancer?

Answer 6

• Initial symptoms are non-specific - anorexia, malaise, weight loss, nausea.
• Later jaundice, epigastric pain.

Uncommon symptoms: thirst, polyuria, nocturia

Question 7

What are the signs of pancreatic cancer on examination?

Answer 7

• Weight loss, epigastric tenderness or mass
• Jaundice and palpable gall bladder (Courvoisier’s law)
• Hepatomegaly (if metastatic spread)
• Trousseau’s sign is associated with superficial thrombophlebitis
• Other: petechiae, purpura, bruising (DIC in advanced disease)

Question 8

What investigations would you do for pancreatic cancer?

Answer 8

Diagnosis:

• Abdo USS - may show pancreatic mass or dilated biliary tree
• CT imaging - GOLD standard for diagnosis and prognosis/ staging
• PET-CT/MRCP - if diagnosis unclear
• CT CAP - staging
• Endoscopic ultrasound +/- FNA - for tissue biopsy staging

Other:

• Tumour markers CA19-9, CEA - high but neither diagnostic
• High bilirubin, high ALP, high GGT - if obstructive jaundice
• Deranged clotting - high PT
• FBC - low platelets in DIC, anaemia in GI bleed
• Staging laparoscopy - identified peritoneal, capsular or serosal involvement or small hepatic metastases not seen on CT

Question 9

What tumour marker is associated with pancreatic cancer? What is its use?

Answer 9

CA19-9 is a tumour marker for pancreatic carcinoma

• High sensitivity and specificity
• Main role is in assessing response to treatment

Question 10

Which of these are true about pancreatic cancer? (3)

• Cigarette smoking is a risk factor
• Diabetes is a risk factor
• Tumours are most common in the tail of the duct gland.
• Encasement of the superior mesenteric vessels does not preclude surgery
• Most lesions arise from exocrine ductal epithelium
• In patients not suitable for surgery, a good response can be expected from chemoradiotherapy.

Answer 10

• Cigarette smoking is a risk factor
• Diabetes is a risk factor
• Most lesions arise from exocrine ductal epithelium

Few patients are suitable for surgery and vessel encasement is a contraindication. 1 year survival rates are very poor. Most tumours occur in the head of the gland.

Question 11

What is the management of pancreatic cancer?

Answer 11

Pancreaticoduodenectomy with antrectomy (Whipple’s) +/- regional lymphadenectomy - if tumour at head of pancreas

Distal pancreatectomy +/- splenectomy with regional lymphadenectomy - for body or tail of pancreas tumours

Adjuvant chemotherapy - for all patients, prolongs survival

Other:

Pancreatic enzyme replacement - Creon

Internal biliary stenting - if obstructive symptoms >10days post-op

Analgesia

Question 12

What is the prognosis with pancreatic cancer?

Answer 12

Stage I/II - only 10-15% have resectable disease and median survival is 15-19months

Stage III/unresectable - poor prognosis with chemo/radiotherapy only having a modest improvement in survival

Stage IV/metastatic - 3-6 month survival

Question 13

What are the complications of pancreatic cancer?

Answer 13

• Cholangitis
• DVT
• PE
• Obstruction
• Surgery related: bleeding, pancreatic leaks, fistula, delayed gastric emptying

Question 14

What is shown?

Answer 14

Pancreaticoduodenectomy