[35] Pancreatic Cancer Flashcards
What will pancreatic cancer typically refer to?
Ductal carcinoma of the pancreas
What % of primary pancreatic malignancies are ductal carcinoma of the pancreas?
Up to 90%
What are the remaining 10% of primary pancreatic malignancies?
Exocrine tumours
Endocrine tumours
Give an example of an exocrine tumour of the pancreas
Pancreatic cystic carcinoma
Give an example of an endocrine tumour of the pancreas?
Tumour derived from islet cells of pancreas
How common is pancreatic cancer compared to other cancers?
10th most common cancer in UK
How deadly is pancreatic cancer compared to other cancers?
4th most common cause of cancer death in UK
What age group does pancreatic cancer occur in?
Rare under 40 years of age, 80% cases occur between 60-80 years
Why does pancreatic cancer have a high mortality?
It is rarely diagnosed early enough for curative treatment
How does the mortality of rarer types of pancreatic tumours differ from that of ductal carcinoma?
They often have a much better prognosis
What does direct invasion of pancreatic ductal carcinoma typically involve?
Spleen
Transverse colon
Adrenal glands
What does the lymphatic metastasis of pancreatic ductal carcinomas typically involve?
Regional lymph nodes, liver, lungs, and peritoneum
Is metastasis common at the time of diagnosis of pancreatic ductal carcinoma?
Yes
What are the risk factors for the development of carcinoma of the pancreas?
Smoking
Chronic pancreatitis
Recent onset of diabetes mellitus
Late onset diabetes
What % of people with pancreatic cancer have a family history of the disease?
7%
By how much does a diagnosis of diabetes after 50 increase the risk of developing pancreatic carcinoma in the next 3 years?
8x
What % of cases of pancreatic carcinoma are unresectable at diagnosis?
80%
Why is pancreatic cancer often diagnosed late?
Due to the late and often vague and non-specific nature of its presentation
What do the specific clinical features of pancreatic carcinoma depend on?
The site of the tumour
How do cancers affecting the head of the pancreas typically present?
Obstructive jaundice
Abdominal pain, radiating to the back
Weight loss
Why do cancers affecting the head of the pancreas cause obstructive jaundice?
Due to compression of the common bile duct
What % of cases of cancer affecting the head of the pancreas have obstructive jaundice at the time of diagnosis?
90%
Why do cancers affecting the head of the pancreas cause abdominal pain radiating to the back?
Due to invasion of the coeliac plexus, or secondary to pancreatitis
Why do cancers affecting the head of the pancreas cause weight loss?
Due to the metabolic effects of the cancer, or secondary to exocrine dysfunction
What are the less common presentations of pancreatic cancer?
Acute pancreatitis
Thrombophlebitis migrans
What is thrombophlebitis migrans?
A recurrent migratory superficial thrombophlebitis
What causes thrombophlebitis migrans in pancreatic cancer?
A paraneoplastic hypercoagulable state
What is the problem with the diagnosis of tumours of the tail of the pancreas?
They have an insidious course, and are generally not symptomatic until a late stage
What may be found on examination in pancreatic cancer?
Patient may appear cachetic, malnourished, and jaundiced
On palpation, and abdominal mass in the epigastric region may be felt, as well as enlarged gallbladder (as per Courvoisier’s Law)
What does Courvoisier’s law state?
That in the presence of jaundice and an enlarged/palpable gallbladder, malignancy of the biliary tree or pancreas should be strongly suspected, as the cause is unlikely to be gallstones
When might Courvoisier’s law be present?
If the obstructing tumour is distal to the cystic duct
What % of patients with pancreatic cancer have an enlarged gallbladder?
Less than 25%
How does pancreatic cancer often present?
With vague, non-specific features
What are the differential diagnoses for obstructive jaundice?
Gallstone disease
Cholangiocarcinoma
Benign gallbladder stricture
What are the differential diagnoses for causes of epigastric abdominal pain?
Gallstones Peptic ulcer disease Pancreatitis Abdominal aortic aneurysm Gastric carcinoma Acute coronary syndrome
What laboratory tests should be done in any suspected pancreatic cancer
Initial blood tests, including FBC and LFTs
What might be shown on FBC in pancreatic cancer?
Anaemia
Thrombocytopenia
What may be shown on LFTs in pancreatic cancer?
Raised bilirubin
Raised alkaline phosphatase
Raised gamma-GT
What is CA19-9?
A tumour marker with high sensitivity and specificity for pancreatic cancer
What is the role of CA19-9?
Assessing response to treatment, rather than for initial diagnosis
What initial imaging is done for pancreatic cancer?
Commonly abdominal ultrasound
What might abdominal ultrasound show in pancreatic cancer?
Pancreatic mass
Dilated biliary tree
Potential hepatic metastases and ascites if very late stage disease
What is the most important investigation in terms of diagnosis of pancreatic cancer?
A pancreatic protocol CT scan
What is the additional use (apart from diagnosis) of a pancreatic protocol CT scan?
It is the most prognostically informative, as it can stage disease progression
What imaging will be required once pancreatic cancer has been diagnosed?
A chest-abdo-pelvis CT scan
What is the purpose of a chest-abdo-pelvis CT scan after the diagnosis of pancreatic cancer?
For staging
What imaging modality may be warranted in those with localised disease on CT who will be having cancer treatment?
PET-CT
How are biopsies be done in pancreatic cancer?
Fine needle aspiration biopsy
What is used to guide a fine needle aspiration biopsy in pancreatic cancer?
Endoscopic ultrasound
What is the purpose of fine need aspiration biopsy in suspected pancreatic cancer?
To histologically evaluate the lesion if diagnosis is unclear
What is the role of ERCP in pancreatic cancer
It can be used to access the lesion for biopsy or cytology if in a suitable location
What is currently the only curative option for pancreatic cancer?
Radical resection
What is the most common surgery with curative intent for patients with tumours of the head of the pancreas?
Pancreaticoduodenectomy, also known as Whipple’s procedure
What surgery can be performed for patients with tumours of the body or the tail of the pancreas?
A distal pancreatectomy
What are the absolute contraindications for surgery in pancreatic cancer?
Peritoneal, liver, and distant metastases
What is the morbidity of surgery for pancreatic cancer?
Up to 40%
What are the specific complications of surgery for pancreatic cancer?
Formation of a pancreatic fistula
Delayed gastric emptying
Pancreatic insufficiency
How can a pancreatic fistula form following surgery for pancreatic cancer?
Due to leakage of pancreatic juices from the incised margin of the pancreas
How does pancreatic resection compare to palliative treatments in patients with locally advanced pancreatic cancer and venous involvement?
It increases survival and reduces costs compared to palliative treatment
What should be considered if possible for people have surgery for head of pancreas cancer?
Pylorus-preserving resection of the tumour
What does a Whipple’s procedure involve?
The removal of the head of the pancreas, the antrum of the stomach, and the 1st and 2nd parts of the duodenum, the common bile duct, and the gallbladder. Following this, the tail of the pancreas and the hepatic duct are attached to the jejenum, allowing bile and pancreatic juices to drain into the gut, whilst the stomach is subsequently anastomosed with the jejenum, allowing for the passage of food
Why is the antrum of the stomach, the 1st and 2nd parts of the duodenum, the common bile duct and the gallbladder removed in a Whipple’s procedure?
Due to their common arterial supply (the gastroduodenal artery), shared by the head of the pancreas and duodenum
What is recommended after surgery for pancreatic cancer?
Adjuvant chemotherapy
What is generally used for adjuvant chemotherapy after surgery for pancreatic cancer?
5-flourouracil
Is neoadjuvant chemotherapy recommended by NICE for pancreatic cancer?
Only for people involved in a clinical trial
What chemotherapy regime is advised in metastatic pancreatic cancer?
FOLFIRINOX regime, in those with a good performance status
What agents are used in the FOLFIRINOX regime?
Folinic acid
5-flurouracil
Irinotecan
Oxaliplatin
What is the limitation of the use of the FOLFIRINOX regime in people with metastatic pancreatic cancer?
It has only achieved modest improvements in survival
What chemotherapy regime is recommended in people with locally advanced pancreatic cancer who are not well enough to tolerate FOLFIRINOX?
Gemcitabine therapy
What is true regarding treatment options for the majority of patients with pancreatic cancer?
They are not candidates for curative surgery, but instead require palliative care
How can obstructive jaundice and associated pruritis be treated in pancreatic cancer?
Insertion of a biliary stent
What are the options for insertion of a biliary stent?
ERCP
Percutaneously
What chemotherapy is used in palliative care for pancreatic cancer?
NICE recommend a gemcitabine-based regime in patients with a reasonable performance status
Where is exocrine insufficiency common in pancreatic cancer?
Advanced disease
Those who have had significant excision of the pancreas
What can exocrine insufficiency lead to in pancreatic cancer?
Malabsorption
Steatorrhoea
How can exocrine insufficiency be treated in pancreatic cancer?
Enzyme replacements including lipases, such as Creon
When are pancreatic enzyme replacements typically administered?
With meals
What have recent studies shown regarding patients undergoing pancreatoduodenectomy for pancreatic cancer and the use of pancreatic enzyme replacement therapy?
It is associated with improved survival
What is the metastatic capacity for pancreatic cancers?
High, even in small tumours
What is the prognosis in pancreatic cancer?
Overall 5 year survival rate is less than 5%
Is tumour size a good indicator of prognosis in pancreatic cancer?
Only in patients with localised disease
Are endocrine tumours of the pancreas functional or non-functional?
Can be either
What are the clinical features of functional endocrine tumours of the pancreas related to?
The active secretion of hormones
What are the clinical features of non-functional endocrine tumours of the pancreas related to?
Purely their malignant spread
What are endocrine tumours of the pancreas often associated with?
Multiple endocrine neoplasia 1 syndrome (MEN1), also known as Wermer’s syndrome
What does MEN1 typically consist of?
Hyperparathyroidism
Endocrine pancreatic tumours
Pituitary tumours, most commonly prolactinomas
What is a tumour of the G cells of the pancreas called?
Gastrinoma
What is the normal physiological function of gastrin?
Stimulates the release of gastric acid
What are the features of a functional gastrinoma?
Zollinger-Ellison syndrome
What does Zollinger-Ellison syndrome cause?
Severe peptic ulcers, refractory to medical treatment
Diarrhoea
Steatorrhoea
What is a tumour of the alpha cells of the pancreas called?
Glucagonoma
What is the normal physiological function of glucagon?
Increase blood glucose concentration
What are the features of a functional glucagonoma?
Hyperglycaemia
Diabetes mellitus
Necrolytic migratory erythema
What is a tumour of the beta cells of the pancreas called?
Insulinoma
What is the normal physiological function of insulin?
Decrease blood glucose concentration
What are the clinical features of a functional insulinoma?
Symptomatic hypoglycaemia, such as sweating or changed metal state, improving with consumption of carbohydrates
What is a tumour of the δ cells of the pancreas called?
Somatostatinoma
What is the normal physiological function of somatostatin?
Inhibits the release of GH, TSH, and prolactin from the AP, and of gastrin
What are the features of a functional somatostatinoma?
Diabetes mellitus Steatorrhoea Gallstones Weight loss Achlorhydria
Why does a somatostatinoma cause gallstones?
Due to inhibition of cholecystokinin
Why does a stomatostatinoma cause achlorhydria?
Due to gastrin inhibition
What is a tumour of the non-islet cells of the pancreas called?
Vasoactive intestinal peptideoma (VIPoma)
What is the normal physiological function of vasoactive intestinal peptide?
Secretion of water and electrolytes into the gut
Relaxation of enteric smooth muscle
What are the features of a functional VIPoma?
Prolonged profuse watery diarrhoea
Severe hypokalaemia
Dehydration
What are the clinical features of a VIPoma also known as?
Verner-Morrison syndrome
Where should all causes of endocrine pancreatic tumours be discussed?
In a MDT meeting in a tertiary hospital, where management can be guided
How are pancreatic endocrine tumours best investigated?
Combination of CT, MRI, and/or EUS
What can be useful for the localisation and assessment of insulinomas and gastrinomas?
Intra-arterial calcium with digital subtraction angiography
When can endocrine tumours of the pancreas just be observed?
When they are small (<1cm), non-functional, and well differentiated
When can endocrine tumours of the pancreas be resected?
When they are larger or functioning, but low grade
Metastatic disease can also be resected if they are low volume
What can be used to control and ameliorate the effects of hormonal hypersecretion?
Somatostatin analogues (even in the case of stomatostatinomas)
