Carcinoma of the Pancreas

Question 1

what is the typical patient that has carcinoma of the pancreas?

Answer 1

• male

- over 70 years old

Question 2

what are the risk factors for carcinoma of the pancreas?

Answer 2

• smoking
• alcohol
• carcinogens
• DM
• chronic pancreatitis
• increased waist circumference (i.e. adiposity)
• possible high red fat or processed meat diet

Question 3

what is the most common pathology?

Answer 3

ductal adenocarcinoma.

metastasise early and present late

Question 4

60% arise in?

Answer 4

pancreas head

Question 5

25% arise in?

Answer 5

body

Question 6

15% arise in?

Answer 6

tail

Question 7

where else could they arise?

Answer 7

• ampulla of vater (ampullarf tumour)
• pancreatic islet (insulinoma, gastronome, glucagnoimas, somastonams, VIPomas)
  both have better prognosis

Question 8

what gene do 95% of mutations have?

Answer 8

KRAS2 gene

Question 9

what do tumours in the head of the pancreas present with?

Answer 9

painless obstructive jaundice

Question 10

what do 75% of tumours in the body and tail present with?

Answer 10

epigastric pain (radiates to back and relieved by sitting forward)

Question 11

what could either cancers cause?

Answer 11

anorexia,
weight loss
diabetes
or acute pancreatitis

Question 12

what are rarer features?

Answer 12

• Thrombophlebitis migrans (e.g. an arm vein becomes swollen and red, then a leg vein)
• Increase calcium
• Marantic endocarditis
• Portal hypertension (splenic vein thrombosis)
• Nephrosis (renal vein metastases)

Question 13

what are signs of pancretic carcinoma?

Answer 13

• jaundice and palpable gallbladder (Courvoiseir’s law)
• epigastric mass
• hepatomegaly
• splenomegaly
• lymphadenopathy
• ascites

Question 14

what would you see for bloods for cholestatitc jaundice?

Answer 14

increased CA 19-9.

its non specific but helps in determining prognosis.

Question 15

what does imaging show?

Answer 15

• US or CT can show a pancreatic mass +- dilated biliary tree +- hepatic metastases
• They can guide biopsy and help staging prior to surgery / stent insertion
• ERCP/MRCP show biliary tree anatomy and may localize the site of obstruction
• EUS – endoscopic sonography is an emerging adjunct for diagnosis and staging.

Question 16

what do most ductal cancers present with?

Answer 16

metastatic disease.

Question 17

what are options for surgery?

Answer 17

Resection (pancreatoduodenectomy: whipple’s) is a major undertaking best considered only where no distant metastases and where vascular invasion is till at a minimum.

Post-op morbidity is high (mortality <5%)
Non-curative resection confers no survival benefit

Question 18

what lesions are the easiest for laparscopic excision

Answer 18

tail lesions

Question 19

what does post op chemotherapy do?

Answer 19

delays disease progression

Question 20

how do you manage palliative jaundice?

Answer 20

Endoscopic or percutaneous stent insertion may help jaundice and anorexia. Rarely, palliative by-pass surgery is done for duodenal obstruction or unsuccessful ERCP.

Question 21

how do you manage pain?

Answer 21

Disabling pain may need big doses of opiates, or radiotherapy.

Coeliac plexus infiltration with alcohol may be done at the time of surgery, or percutaneously.
Referral to a palliative care team is essential.

Question 22

what is the prognosis like?

Answer 22

Often dismal.

Mean survival <6months. 5 year survival:

3% overall 5yr survival after Whipple’s procedure 5-14%.

Question 23

when is prognosis better?

Answer 23

• Tumour is less than 3cm
• No nodes involved
• -ve resection margins at surgery
• ampullary or islet cell tumours

Question 24

when can Whipple’s procedure be used?

Answer 24

to remove massess in the head of the pancreas typically from pancreatic carcinoma or rarely a carcinoid tumour