Hepatobiliary cancers: Pancreatic cancer

Question 1

Definition

Answer 1

Adenocarcinoma of exocrine pancreas of DUCTAL origin typically affecting HEAD developing from pre-invasive pancreatic intraepithelial neoplasia
- 60% head
- 25% body
- 15% tail

Question 2

Epidemiology

Answer 2

MALE
60+

Question 3

Risk factors

Answer 3

Smoking
Alcohol
DM
FHx
Chronic pancreatitis
Genetic predisposition:
- hereditary non-polyposis colorectal carcinoma
- BRCA1 + BRCA 2
- Peutz-Jeghers syndrome
Multiple endocrine neoplasia

Question 4

Aetiology

Answer 4

• Faulty K-RAS gene (a proto-oncogene)
• More invasive subtypes tend to also carry CDKN2A (p16), p53 and SMAD4

Question 5

Signs

Answer 5

Positive Courvoisier’s sign:
- In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
Trousseau sign of malignancy: migratory thrombophlebitis

Question 6

Symptoms

Answer 6

Painless jaundice: classical finding
Non-specific symptoms:
- epigastric or atypical back pain,
- anorexia,
- weight loss
New-onset diabetes
- Thirst,
- polyuria,
- nocturia,
- weight loss
Nausea and vomiting
Steatorrhea
Dark urine and pale stools: associated with obstructive jaundice

Question 7

Diagnosis

Answer 7

FIRST LINE = Abdo USS
LFTs: Obstructive picture = raised ALP, GGT and bilirubin
Coagulation profile: Possibility of liver metastasis
GOLD STANDARD: CT (or MRI) pancreas
CA 19-9: Tumour marker = can be used to monitor disease progression but is not diagnostic

Question 8

Treatment

Answer 8

Localised tumour = Surgical resection
- Whipple’s resection:
- Adjuvant chemotherapy: offered after surgery

Locally advanced or metastatic = Palliative management:
- ERCP with stenting: for symptomatic relief of obstructive jaundice in patients with unresectable and metastatic tumours
- Chemotherapy/chemoradiotherapy: offered if patients are able to tolerate it

Question 9

Complications

Answer 9

VTE
T2DM
Cholangitis
Surgery related injury
- Early dumping syndrome - 30 mins = dizziness and palp
- Late dumping syndrome - 2 hours = hyperinsulinemia + hypoglycaemia
- Peptic ulcer disease