Pancreatic cancer

Question 1

function of pancreas

Answer 1

-excretes enzymes to break down fats , carbs , protein, and nucleic acid in food

-secretes insulin and glucagon to control blood sugar levels

Question 2

Types of Pancreatic Cancer:
most common

Answer 2

ductal adenocarcinoma 80-90%

Question 3

Prognosis

Answer 3

carries a high mortality rate
1 year survival=24%
5 year survival=9%

Question 4

Aetiology

Answer 4

-smoking- 20% of cancer
-hereditary-10% (genetic predisposition or inherited cancer syndromes)
-chronic pancreatitis
-genetic disorders associated with the BRCA1, BRCA2, PALB2, and ATM genes
-obesity

Question 5

signs and symptoms

Answer 5

-early stages is usually asymptomatic
-80% of patients are diagnosed at late stages

Question 6

signs and symptoms: early onset symptoms

Answer 6

-abdominal pain
-bloating
-flatulence
-vomiting
-change in bowel habits (constip or dia)

Question 7

signs and symptoms: late onset symptoms

Answer 7

-abdominal or mid back pain
-obstructive jaudince (caused by compression of distal common bile duct)
-weight loss
-dark urine or light colour stool

Question 8

Diagnostic Workup: Imaging used to

Answer 8

-define anatomy- is there a mass and what is the extent
-determine pathology -fine needle aspiration by EUS or CT
-dictate management- is the cancer restectable

Question 9

indications of imaging modalities used to investigate pancreatic tumours:
-US
-CT
-MRI
-ENDOSCOPIC ULTRASOUND

Answer 9

-primary investigation for jaundice and epigastric pain
-investigation of choice for when pancreatic cancer is suspected
-used when CT findings are inconclusive
-problem solver. Most useful when there is a biliary obstruction w no definite mass in CT or MRI

Question 10

what is biomarkers

Answer 10

looks for genes , proteins and other substances that gives info about the cancer

Question 11

Biomarkers for Differential Diagnosis:
CA-19 features

Answer 11

-NOT FOR screening
-poor predictive value for cancer
-CA-19 value will still be normal w patients in early stage
-when elevated indicates advanced stage cancer
-may be more useful in surveillance

Question 12

stage IA & IB

Answer 12

purely based on size of tumour
T1= less than or 2cm
T2=inbetween 2 and 4cm

Question 13

Stage IIA

Answer 13

T3 ( greater than 4cm) but N= -ve

Question 14

Stage IIA

Answer 14

T1,T2 or T3
N1

Question 15

stage IIB

Answer 15

T1, T2 or T3
N1 = Stage IIB disease

Question 16

stage III

Answer 16

Irrespective of T status,
N2 = Stage III OR T4, any N
cancer is 4 or more lymph nodes

Question 17

Stage IV

Answer 17

Irrespective of T and N status,
M +ve

Question 18

Treatment Options

Answer 18

• resectable = neo or adj RT
  -locally adv or unresectable= palli or neo(surgery after)
  -metastatic= palli

Question 19

An MDT approach is imperative…

Answer 19

-onc
-surgeon
-radiologist
-gastroenterologist
-RO
-pathologist
-social worker
-dietician

Question 20

Contraindications for resection include:

Answer 20

-liver, lung and peritoneal mets
-distant LN
-aortic invasion or encasement
-major encasement of SMA,SMV, ceolic or hepatic arteries

Question 21

At time of diagnosis

Answer 21

-20% have resectable tumour
-30% locally advanced tumour that is unresectable
-50% have metastatic disease

Question 22

tx options for resectable or borderline resectable

Answer 22

-neo therapy
-surgery
-postoperative chemo
-postoperative chemoRT

Question 23

tx options for locally advanced pancreatic cancer

Answer 23

-chemo w or w/o targeted therapy
-chemoRT
-surgery
-palli surgery

Question 24

tx options for metastic or recurrent pancreatic cancer

Answer 24

-chemo w or w/o targeted therapy

Question 25

Neoadjuvant Treatments:Key messages for -locally advanced stage disease -borderline resectable disease -resectable disease

Answer 25

-yes as it may enable surgical resection -important role -more evidence needed however in 2023, No impact on OS or DFS; however, improved the chance of R0 resectability

Question 26

Surgical Management: Stage I and II

Answer 26

-surgical resection -distal pracreatectomy with splenectomy -pancreaticduodenectomy "whipple procedure"

Question 27

surgical resection

Answer 27

-total pancreatectomy doesnt improve survival compared to partial resection

Question 28

-distal pracreatectomy with splenectomy

Answer 28

used for body and tail cancers

Question 29

-pancreaticduodenectomy "whipple procedure"

Answer 29

used for cancers in head of pancreas

Question 30

-pancreaticduodenectomy "whipple procedure"

Answer 30

used for cancers at the head of pancreas

Question 31

Adjuvant Treatments for Stage I and II: for who when

Answer 31

-For surgical patients with curative intent -Within 12 weeks post surgery; typically adjuvant chemo

Question 32

-Approx how many of patients don’t go on to receive the intended adjuvant treatments? -why?

Answer 32

«25% «-surgical complications -poor performance status and co-morbidities -patient refusal -disease relapse

Question 33

Adjuvant Treatments for Stage I and II: The role of chemotherapy as per NCI 2022

Answer 33

-for patient w good PS: adjuvant FOLFIRINOX or combination of gemcitabine and capecitabine -for older patients or patients w poorer PS: adjuvant gemcitabine or 5FU as a single agent therapy