[35] Pancreatic Cancer Flashcards
1
Q
What will pancreatic cancer typically refer to?
A
Ductal carcinoma of the pancreas
2
Q
What % of primary pancreatic malignancies are ductal carcinoma of the pancreas?
A
Up to 90%
3
Q
What are the remaining 10% of primary pancreatic malignancies?
A
Exocrine tumours
Endocrine tumours
4
Q
Give an example of an exocrine tumour of the pancreas
A
Pancreatic cystic carcinoma
5
Q
Give an example of an endocrine tumour of the pancreas?
A
Tumour derived from islet cells of pancreas
6
Q
How common is pancreatic cancer compared to other cancers?
A
10th most common cancer in UK
7
Q
How deadly is pancreatic cancer compared to other cancers?
A
4th most common cause of cancer death in UK
8
Q
What age group does pancreatic cancer occur in?
A
Rare under 40 years of age, 80% cases occur between 60-80 years
9
Q
Why does pancreatic cancer have a high mortality?
A
It is rarely diagnosed early enough for curative treatment
10
Q
How does the mortality of rarer types of pancreatic tumours differ from that of ductal carcinoma?
A
They often have a much better prognosis
11
Q
What does direct invasion of pancreatic ductal carcinoma typically involve?
A
Spleen
Transverse colon
Adrenal glands
12
Q
What does the lymphatic metastasis of pancreatic ductal carcinomas typically involve?
A
Regional lymph nodes, liver, lungs, and peritoneum
13
Q
Is metastasis common at the time of diagnosis of pancreatic ductal carcinoma?
A
Yes
14
Q
What are the risk factors for the development of carcinoma of the pancreas?
A
Smoking
Chronic pancreatitis
Recent onset of diabetes mellitus
Late onset diabetes
15
Q
What % of people with pancreatic cancer have a family history of the disease?
A
7%
16
Q
By how much does a diagnosis of diabetes after 50 increase the risk of developing pancreatic carcinoma in the next 3 years?
A
8x
17
Q
What % of cases of pancreatic carcinoma are unresectable at diagnosis?
A
80%
18
Q
Why is pancreatic cancer often diagnosed late?
A
Due to the late and often vague and non-specific nature of its presentation
19
Q
What do the specific clinical features of pancreatic carcinoma depend on?
A
The site of the tumour
20
Q
How do cancers affecting the head of the pancreas typically present?
A
Obstructive jaundice
Abdominal pain, radiating to the back
Weight loss
21
Q
Why do cancers affecting the head of the pancreas cause obstructive jaundice?
A
Due to compression of the common bile duct
22
Q
What % of cases of cancer affecting the head of the pancreas have obstructive jaundice at the time of diagnosis?
A
90%
23
Q
Why do cancers affecting the head of the pancreas cause abdominal pain radiating to the back?
A
Due to invasion of the coeliac plexus, or secondary to pancreatitis
24
Q
Why do cancers affecting the head of the pancreas cause weight loss?
A
Due to the metabolic effects of the cancer, or secondary to exocrine dysfunction
25
What are the less common presentations of pancreatic cancer?
Acute pancreatitis
| Thrombophlebitis migrans
26
What is thrombophlebitis migrans?
A recurrent migratory superficial thrombophlebitis
27
What causes thrombophlebitis migrans in pancreatic cancer?
A paraneoplastic hypercoagulable state
28
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
29
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)
30
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
31
When might Courvoisier's law be present?
If the obstructing tumour is distal to the cystic duct
32
What % of patients with pancreatic cancer have an enlarged gallbladder?
Less than 25%
33
How does pancreatic cancer often present?
With vague, non-specific features
34
What are the differential diagnoses for obstructive jaundice?
Gallstone disease
Cholangiocarcinoma
Benign gallbladder stricture
35
What are the differential diagnoses for causes of epigastric abdominal pain?
```
Gallstones
Peptic ulcer disease
Pancreatitis
Abdominal aortic aneurysm
Gastric carcinoma
Acute coronary syndrome
```
36
What laboratory tests should be done in any suspected pancreatic cancer
Initial blood tests, including FBC and LFTs
37
What might be shown on FBC in pancreatic cancer?
Anaemia
| Thrombocytopenia
38
What may be shown on LFTs in pancreatic cancer?
Raised bilirubin
Raised alkaline phosphatase
Raised gamma-GT
39
What is CA19-9?
A tumour marker with high sensitivity and specificity for pancreatic cancer
40
What is the role of CA19-9?
Assessing response to treatment, rather than for initial diagnosis
41
What initial imaging is done for pancreatic cancer?
Commonly abdominal ultrasound
42
What might abdominal ultrasound show in pancreatic cancer?
Pancreatic mass
Dilated biliary tree
Potential hepatic metastases and ascites if very late stage disease
43
What is the most important investigation in terms of diagnosis of pancreatic cancer?
A pancreatic protocol CT scan
44
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
45
What imaging will be required once pancreatic cancer has been diagnosed?
A chest-abdo-pelvis CT scan
46
What is the purpose of a chest-abdo-pelvis CT scan after the diagnosis of pancreatic cancer?
For staging
47
What imaging modality may be warranted in those with localised disease on CT who will be having cancer treatment?
PET-CT
48
How are biopsies be done in pancreatic cancer?
Fine needle aspiration biopsy
49
What is used to guide a fine needle aspiration biopsy in pancreatic cancer?
Endoscopic ultrasound
50
What is the purpose of fine need aspiration biopsy in suspected pancreatic cancer?
To histologically evaluate the lesion if diagnosis is unclear
51
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
52
What is currently the only curative option for pancreatic cancer?
Radical resection
53
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
54
What surgery can be performed for patients with tumours of the body or the tail of the pancreas?
A distal pancreatectomy
55
What are the absolute contraindications for surgery in pancreatic cancer?
Peritoneal, liver, and distant metastases
56
What is the morbidity of surgery for pancreatic cancer?
Up to 40%
57
What are the specific complications of surgery for pancreatic cancer?
Formation of a pancreatic fistula
Delayed gastric emptying
Pancreatic insufficiency
58
How can a pancreatic fistula form following surgery for pancreatic cancer?
Due to leakage of pancreatic juices from the incised margin of the pancreas
59
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
60
What should be considered if possible for people have surgery for head of pancreas cancer?
Pylorus-preserving resection of the tumour
61
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
62
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
63
What is recommended after surgery for pancreatic cancer?
Adjuvant chemotherapy
64
What is generally used for adjuvant chemotherapy after surgery for pancreatic cancer?
5-flourouracil
65
Is neoadjuvant chemotherapy recommended by NICE for pancreatic cancer?
Only for people involved in a clinical trial
66
What chemotherapy regime is advised in metastatic pancreatic cancer?
FOLFIRINOX regime, in those with a good performance status
67
What agents are used in the FOLFIRINOX regime?
Folinic acid
5-flurouracil
Irinotecan
Oxaliplatin
68
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
69
What chemotherapy regime is recommended in people with locally advanced pancreatic cancer who are not well enough to tolerate FOLFIRINOX?
Gemcitabine therapy
70
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
71
How can obstructive jaundice and associated pruritis be treated in pancreatic cancer?
Insertion of a biliary stent
72
What are the options for insertion of a biliary stent?
ERCP
| Percutaneously
73
What chemotherapy is used in palliative care for pancreatic cancer?
NICE recommend a gemcitabine-based regime in patients with a reasonable performance status
74
Where is exocrine insufficiency common in pancreatic cancer?
Advanced disease
| Those who have had significant excision of the pancreas
75
What can exocrine insufficiency lead to in pancreatic cancer?
Malabsorption
| Steatorrhoea
76
How can exocrine insufficiency be treated in pancreatic cancer?
Enzyme replacements including lipases, such as Creon
77
When are pancreatic enzyme replacements typically administered?
With meals
78
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
79
What is the metastatic capacity for pancreatic cancers?
High, even in small tumours
80
What is the prognosis in pancreatic cancer?
Overall 5 year survival rate is less than 5%
81
Is tumour size a good indicator of prognosis in pancreatic cancer?
Only in patients with localised disease
82
Are endocrine tumours of the pancreas functional or non-functional?
Can be either
83
What are the clinical features of functional endocrine tumours of the pancreas related to?
The active secretion of hormones
84
What are the clinical features of non-functional endocrine tumours of the pancreas related to?
Purely their malignant spread
85
What are endocrine tumours of the pancreas often associated with?
Multiple endocrine neoplasia 1 syndrome (MEN1), also known as Wermer's syndrome
86
What does MEN1 typically consist of?
Hyperparathyroidism
Endocrine pancreatic tumours
Pituitary tumours, most commonly prolactinomas
87
What is a tumour of the G cells of the pancreas called?
Gastrinoma
88
What is the normal physiological function of gastrin?
Stimulates the release of gastric acid
89
What are the features of a functional gastrinoma?
Zollinger-Ellison syndrome
90
What does Zollinger-Ellison syndrome cause?
Severe peptic ulcers, refractory to medical treatment
Diarrhoea
Steatorrhoea
91
What is a tumour of the alpha cells of the pancreas called?
Glucagonoma
92
What is the normal physiological function of glucagon?
Increase blood glucose concentration
93
What are the features of a functional glucagonoma?
Hyperglycaemia
Diabetes mellitus
Necrolytic migratory erythema
94
What is a tumour of the beta cells of the pancreas called?
Insulinoma
95
What is the normal physiological function of insulin?
Decrease blood glucose concentration
96
What are the clinical features of a functional insulinoma?
Symptomatic hypoglycaemia, such as sweating or changed metal state, improving with consumption of carbohydrates
97
What is a tumour of the δ cells of the pancreas called?
Somatostatinoma
98
What is the normal physiological function of somatostatin?
Inhibits the release of GH, TSH, and prolactin from the AP, and of gastrin
99
What are the features of a functional somatostatinoma?
```
Diabetes mellitus
Steatorrhoea
Gallstones
Weight loss
Achlorhydria
```
100
Why does a somatostatinoma cause gallstones?
Due to inhibition of cholecystokinin
101
Why does a stomatostatinoma cause achlorhydria?
Due to gastrin inhibition
102
What is a tumour of the non-islet cells of the pancreas called?
Vasoactive intestinal peptideoma (VIPoma)
103
What is the normal physiological function of vasoactive intestinal peptide?
Secretion of water and electrolytes into the gut
| Relaxation of enteric smooth muscle
104
What are the features of a functional VIPoma?
Prolonged profuse watery diarrhoea
Severe hypokalaemia
Dehydration
105
What are the clinical features of a VIPoma also known as?
Verner-Morrison syndrome
106
Where should all causes of endocrine pancreatic tumours be discussed?
In a MDT meeting in a tertiary hospital, where management can be guided
107
How are pancreatic endocrine tumours best investigated?
Combination of CT, MRI, and/or EUS
108
What can be useful for the localisation and assessment of insulinomas and gastrinomas?
Intra-arterial calcium with digital subtraction angiography
109
When can endocrine tumours of the pancreas just be observed?
When they are small (<1cm), non-functional, and well differentiated
110
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
111
What can be used to control and ameliorate the effects of hormonal hypersecretion?
Somatostatin analogues (even in the case of stomatostatinomas)
