Pancreatic cancer

Question 1

what’s the most common form of cancer in the pancreas? where does it usually occur?

Answer 1

ductal carcinoma at the head of the pancreas

Question 2

what is the prognosis for ductal carcinoma of the pancreas and why?

Answer 2

very poor prognosis as it usually presents quite late and rarely early enough for curative treatment.
metastasizes early to lymph nodes, peritoneum, and liver (portal drainage)

Question 3

what are the risk factors for developing pancreatic carcinomas?

Answer 3

• smoking
• chronic pancreatitis
• recent onset of diabetes
• FHx
• late-onset of diabetes (above 50)

Question 4

what are the clinical features of ductal pancreatic carcinomas of the head and why do they develop?

Answer 4

• obstructive jaundice: compression of the bile duct)
• -> typically painless early on and leads to steatorrhea and dark urine
• Abdo pain (deep gnawing epigastric) : invasion of the coeliac plexus / secondary to pancreatitis
• weight loss- cancer/ exocrine dysfunction

less common:

• steatorrhea
• pancreatitis
• diabetes Mellitus
• thrombophlebitis migrans –> repeated thrombosis of superficial veins – hypercoagulable state

Question 5

what is Courvoisier’s law??

Answer 5

In the presence of jaundice and an enlarged/palpable gallbladder, the gall bladder is unlikely to be the cause, therefore, malignancy of the biliary tree/pancreas should be considered

• gall stones –> chronic inflammation –> fibrosis and hypertrophy of the gall- bladder wall –> unlikely to distend.
  in cancers the obstruction develops quickly, therefore, the gall bladder wall can distend

Question 6

what are some of the differential diagnoses for pancreatic ca??

Answer 6

obstructive jaundice: gall stone obstruction, cholangiocarcinoma, benign gall bladder stricture

epigastric Abdo pain - peptic ulcer, gall stone disease, MI, GORD, oesophagitis, pancreatitis, AAA

Question 7

what investigations are performed in suspected pancreatic cancer?
what are the findings

Answer 7

lab tests
- FBC: anaemia / thrombocytopenia
- LFTs: raised bilirubin, ALP and GGT –> obstructive
(CA19-9 used more for tracking treatment rather than initial diagnosis)

imaging
USS - pancreatic mass/dilation of the biliary tree (liver metastases in late-stage)
a pancreatic protocol CT scan - tumour extent/ liver metastases/ vascular invasion in SMA/ coeliac axis
PET CT - looks for metastases
EUS - fine-needle aspiration to evaluate lesion for treatment or diagnosis. can also show added detail to determine if the lesion is resectable
MRCP/ERCP - diagnosis of gall stone/ biliary tree pathology

Question 8

what is the surgical management for ductal pancreatic ca??

Answer 8

cancers in the head of the pancreas:

• Whipple’s procedure (pancreaticoduodenectomy):
  1) involves removal of the antrum of the stomach, the head of the pancreas, 1st and 2nd part of duodenum, common bile duct and the gallbladder. –> all have common arterial supply - gastroduodenal artery
  2) tail of pancreas and hepatic duct attached to the jejunum (allow juices to flow into bowel) and stomach anastomosed with the jejunum
• check teach me surgery diagram
• adjuvant chemotherapy (5-fluorouracil) after surgery

Question 9

Outline the palliative care of ductal pancreatic adenocarcinma.

Answer 9

this is done for the majority of patients

surgical:
- a biliary stent may be put in via ERCP to relieve jaundice and itching
- triple bypass operation

chemotherapy may be initiated

exocrine insufficiency (especially post Whipple’s): Creon

Question 10

what is the prognosis for ductal adenocarcinoma?

Answer 10

5- year survival is less than 5%

Question 11

describe teh difference between sunction and non-function endocrine tumours?

Answer 11

functional: actively secrete hormone –> signs and symptoms associated with this
non-functionl: dont secret hormones –> signs and symptoms due to maliganat spread

Question 12

what is an endocrine cancer of the B cells and how does it present?

Answer 12

insulinoma

symptomatic hypogltcaemia : seating, changing mental state -improving with consumption of carbs

*investigations: hyperinsulanemaia –> CT
usually benign

Question 13

what cells are affected in glucagonomas?

what are the clinical features?

Answer 13

affects alpha cells

hyperglycaemia –> diabetes mellitis and migratory necrolytic erythema (skin condition - check images)

Question 14

what is zollinger-ellison syndrome?

how does it present ?

Answer 14

cancer of the G cells –> gastrinoma

severe peptic ulcers
diarrhoea

Question 15

what cells are affected in somatastatinomas?

what are thee clinical features?

Answer 15

delta cells

diabetes mellitus
steatorrhea, gallstones –> inchibition of CCK
weight loss and reduced HCL –> inhibition of gastrin

Question 16

what are the Multiple Endocrine Neoplasia syndromes?

Answer 16

these are autosomal dominant inherited syndroms.
thesere 3 forms :

MEN1 : islet cell tumours, pituatary adenoma and Parathyroid hyperplasia
MEN2a: medullary thyroid ca (esp in childhood), phaechromocytoma and parathyroid hyperplasia/ adenoma
MEN2b: medullary thyroid ca, phaechromocytoma and mucosal/GI neurofibromas and marfanoid habitus(syndrome of marfan’s symptoms)

Question 17

what are the general principle of investigation and managemnt in endocrine pancreatic ca?

Answer 17

investigations: CT, MRI +/- EUS
management :
small non-functional = observed
larger/functioning: resected

Question 18

which type of cystic neoplasm is most likely to become malignant and which is less likely?

Answer 18

mucinous cyst = more likely to become malignant

serous cyst = less likely to become malignant

Question 19

what are the investigations performed for a potential cystic neoplasm?

Answer 19

typically CT and EUS allow aspiration for cytology. these help to differentiate between pseudocysts, serous and mucinous adenocarcinoma,s and cystadenocarcinoma

Question 20

what are the treatments for different cysts?

Answer 20

mucinous cyst –> resection
serous cyst –> observation
and cancerous cysts –> resection