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YR3 SURGERY HPB > pancreatic cancer > Flashcards

pancreatic cancer Flashcards

1
Q

what type of pancreatic cancers are there?

A
  • ductal carcinomas of the pancreas (90%)
  • exocrine tumours e.g pancreatic cystic carcinoma
  • endocrine tumours from islet cells
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2
Q

what are group usually experiences pancreatic cancer?

A

60-80 years old

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3
Q

whats the mortality rate like?

A

high, with diagnosis usually too late for curative treatment

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4
Q

what local structures are usually involved as the cancer spreads?

A

direct invasion involves

  • spleen
  • transverse colon
  • adrenal glands

lymphatic metasteses involves

  • regional lymph nodes
  • liver
  • lungs
  • peritoneum

metastasis is common at the time of diagnosis

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5
Q

what are the risk factors for pancreatic cancer?

A
  • smoking
  • chronic pancreatitis
  • family history
  • late onset diabetes mellitus
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6
Q

how does pancreatic cancer present?

A

most cases of pancreatic carcinoma are unresectable at diagnosis, a testament to the late, vague and non specific signs

specific clinical features can depend on the site of tumour

head of the pancreas can present with

  • obstructive jaundice (compression of common bile duct)
  • abdominal pain radiating to the back due to invasion of coeliac plexus or 2ndry to pancreatitis
  • weight loss due to metabolic effects of cancer, or 2ndry to endocrine dysfunction
  • acute pancreatitis
  • thrombophlebitis migrant

Tumours of the tail of the pancreas have an insidious course and are often not symptomatic till a late stage

on examination

  • cachectic
  • malnourished
  • jaundiced
  • abdominal mass in epigastric region
  • enlarged gall bladder
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7
Q

what are your differentials for causes of obstructive jaundice?

A
  • gallstone disease
  • cholangiocarcinoma
  • benign gallbladder stricture
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8
Q

what are your differentials for causes of epigastric abdominal pain?

A
  • gallstones
  • peptic ulcer disease
  • gastric carcinoma
  • acute coronary syndrome
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9
Q

what laboratory tests can be done to investigate pancreatic cancer?

A

initial blood tests including

  • FBC ( anaemia or thrombocytopenia)
  • LFTs (raised bilirubin, alkaline phosphatase, gamma GT, showing obstructive jaundice picture)
  • CA19-9 is a tumour marker with high sensitivity and specify for pancreatic cancer, however usually used for assessing response to treatment rather than initial diagnosis
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10
Q

what imaging can be done for pancreatic cancer?

A
  • abdominal ultrasound may show pancreatic mass/ dilated biliary tree (or hepatic metastases/ascites if late stage
  • CT imaging aids diagnosis and is prognostically informative as can stage disease progression
  • chest abdomen pelvis CT once diagnosed for staging
  • PET CT if localised disease on CT but will be having cancer treatment
  • endoscopic ultrasound (EUS) can be used for fine needle aspiration biopsy to histologically evaluate lesion
  • ERCP can be used to access lesion for biopsy or cytology if its in suitable location
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11
Q

what is the surgical management for pancreatic tumours?

A
  • radial resection is the only curative option
  • tumour of head of pancreas, commonly get a pancreaticoduodenectomy, aka a whiles procedure.
  • tumours of body/tail, distal pancreatectomy can be performed
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12
Q

what are the contraindications for surgery?

A

peritoneal, liver and distant metasteses

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13
Q

what are the specfific complications of surgery?

A

pancreatic fistula

delayed gastric emptying

pancreatic insufficiency

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14
Q

when is chemotherapy recommended and what is used?

A

adjuvant chemotherapy is recommended after surgery

usually use 5-flourouracil

metastatic disease, use of the FLOFIRNOX regime of 4 medications is advised in those with a good performance status, but only has modest improvements in survival

gemcitabine therapy can be considered for those who aren’t well enough to tolerate FLOFIRINOX

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15
Q

what is used for palliative care?

A

majority of people will need palliative care

  • insert biliary stent via ERCP or percutaneously to relieve obstructive jaundice and associated pruritis
  • palliative chemo with a gemcitabine based regime in patients with good performance status
  • exocrine insufficiency with associated malabsorption and steatorrhoea can be treated with enzyme replacements (including lipase) e.g creon
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16
Q

what are endocrine tumours of the pancreas?

A

neoplasms that can be functional and secrete hormones with related signs and symptoms or non functional

non functional tumours do not secrete active hormones and clinical features are related to their malignant spread

17
Q

what is multiple endocrine neoplasia 1 syndrome (MEN1)?

A

endocrine tumours are usually associated with MEN1

it consist of

  • hyperparathyroidism
  • endocrine pancreatic tumours
  • pituitary tumours, usually prolactinomas
18
Q

what determines the clinical features?

A

the type of cell affected and what each cell produces

19
Q

what do the following pancreatic cells produce and what can a tumour of these cells cause

G cells
a cells
B cells
δ cells
non islet cells
A

G cells = gastrin to stimulate release of gastric acid. Tumour = too much gastric acid = peptic ulcers

a cells = glucagon. increase blood glucose. tumour = hyperglycaemia, DM.

B cells = insulin. decrease blood glucose. Tumour = hypoglycaemia with sweating, changed mental state, improved with eating carbs

δ cells = somatostatin. inhibits GH, TSH, prolactin and gastrin release. Tumour = DM, steatorrhea, gallstones (due to CCK inhibition), weight loss

non islet cells = vasoactive intestinal peptide. secretes water and electrolytes into gut and relaxes enteric smooth muscle. Tumour = watery diarrhoea, severe hypokalaemia, dehydration.

20
Q

what investigations are done into endocrine pancreatic tumours?

A
  • MDT discussion
  • use CT, MRI and/or endoscopic ultrasound.
  • intra-arterial calcium with digital subtraction angiography can also be used in insulinomas and gastronomes
21
Q

what is the management for endocrine pancreatic tumours?

A
  • well differentiated small pancreatic NETs than are non functional can just be observed
  • larger/functioning can be resected with any distant metastatic disease also resected if tumour is low grade and metastases is low volume
  • somatostatin analogues can be used to control effects of hormonal hyper secretion
22
Q

what is removed in a whipples procedure?

A

head of the pancreas, the antrum of the stomach, the 1st and 2nd parts of the duodenum, the common bile duct, and the gallbladder

23
Q

what is the imaging of choice for insulinomas?

A

upper endoscopic ultrasound

YR3 SURGERY HPB (13 decks)

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