Pancreatic Cancer

Question 1

what is the typical presentation of pancreatic cancer?

Answer 1

painless jaundice

palpable gallbladder

pancreatic protocol CT with chest abdo and pelvis

sudden onset DM

CA19-9 and ALP elevated

Question 2

define pancreatic cancer?

Answer 2

primary pancreatic ductal adenocarcinoma

malignancy arising from exocrine ( more common) and endocrine tissues of pancreas

Question 3

what is the most common type of pancreatic cancer?

Answer 3

ductal adenocarcinoma

Question 4

where are the locations of pancreatic cancer?

Answer 4

75% occur within head or neck of pancreas.

15-20% occur in body

5-10% in tail

Question 5

whata are the risk factors for pancreatic cancer?

Answer 5

Age

Smoking

FH (of cancer and other cancer conditions)

5-10% are hereditary (e.g. MEN, HNPCC, FAP, Von-Hippel Lindau syndrome)

Alcohol

Diabetes mellitus

Chronic pancreatitis

Dietary (low intake of fresh fruit and vegetables, high fat and red/processed meat)

Inc waist circumference

Question 6

summarise the epidemiology of pancreatic cancer?

Answer 6

Increasing incidence: 8-12/100,000

2 x more common in MALES

Peak age: 60-80 yrs

Question 7

what are the presenting symptoms of pancreatic cancer?

Answer 7

FLAWS

Anorexia

Malaise

Should be excluded in patients with acute pancreatitis which is unexplained with N+V+anorexia+midepigastric pain

Epigastric pain– radiates to back and relieved by sitting forward (75% of tumours in body and tail present with this)

Weight loss

Diabetes mellitus symp like thirst, poluria and nocturia

Jaundice (tumours of head usually present with this)

Question 8

what are the signs of pancreatic cancer on physical examination?

Answer 8

Weight loss

Epigastric tenderness or mass (late stages)

Jaundice and a palpable gallbladder (Courvoisier’s law- a palpable gallbladder with painless jaundice is unlikely to be due to gallstones – advanced stages)

If metastatic spread –> hepatomegaly/splenomegaly/lymphadenopathy

Signs of DIC in advanced disease(petechiae, purpura, bruising)

Trousseau’s Sign of Malignancy - superficial thrombophlebitis

Question 9

what are the appropriate investigations for pancreatic cancer?

Answer 9

LFTs

abdo ultrasound

pancreatic protocol CT

Question 10

describe LFTs in pancreatic cancer?

Answer 10

can cause obstructive jaundice:

High bilirubin

High ALP

High GGT

Deranged clotting

Imaging – can show pancreatic mass +/- dilated biliary tree +/- hepatic metastases

Question 11

what can be seen on the ultrasound in pancreatic cancer?

Answer 11

Pancreatic mass, dilated bile ducts and liver metastases

Question 12

what investigatiosn would you consider for pancreatic cancer?

Answer 12

CA 19-9 and CEAa re tumour markers – both elevated with CA-19 being more specific, but neither are diagnostic

Prolonged PT

Plts decrease in DIC and anaemia in GI bleeding

PET if CT is unclear

ERCP – ampullary tumour may be seen and other tumours only detectable if there is pancreatic duct involvement

NOTE: diagnoses by histology is not required before surgical resection as it should not delay surgical treatment; however, if patient has advanced, unresectable disease, biopsy may be required for palliative therapy confirmation