Pancreas

Question 1

Where do the majority of pancreatic cancers occur?

Answer 1

80% within the head of the pancreas

Question 2

What does back pain that is relieved by sitting forward suggest?

Answer 2

Infiltration of retroperitoneal mets (1st & 2nd coeliac ganglia)

Question 3

What investigations should you perform for pancreatic cancer?

Answer 3

Bloods
Ca19-9 (raised in 70%) - can be falsely high in obstructive jaundice
CT TAP (contrast pancreatic protocol) - dual phase helical CT
PET-CT (if localised disease considering resection - PET-PANC trial stopped resection in 20%)
MR liver (r/o metastatic disease)
ERCP useful if presentation with obstructive jaundice
EUS FNA if brushing a negative

Question 4

Describe T1

Answer 4

<=2cm

T1a <=0.5cm
T1b 0.5-1cm
T1c 1-2cm

Question 5

Describe T2

Answer 5

2-4cm

Question 6

Describe T3

Answer 6

> 4cm

Question 7

Describe T4

Answer 7

Involves coeliac axis, SMA +- common hepatic artery

Question 8

Describe the N stage

Answer 8

1-3 regional LN = N1

>=4 regional LN = N2

Question 9

What is the resectability criteria for pancreatic tumours?

Answer 9

No contact with the coeliac axis, SMA or CHA
No contact with SMV or PV or <180deg contact without vessel irregularity
Splenic vein involvement doesn’t always mean its unresectable

Question 10

What operation would be performed for a resectable pancreatic tumour involving the head of the pancreas?

Answer 10

Pancreaticoduodenectomy (whipples) with standard lymphadenectomy

Question 11

What operation would be performed for a lesion in the body or tail of the pancreas?

Answer 11

Distal pancreatectomy with standard lymphadenectomy

Question 12

What adjuvant treatment is given following surgical resection?

Answer 12

1. mFOLFIRINOX (need to be PS 0-1), based on PRODIGE trial (v gem), mOS 54 months (v35m)

If unfit for above, consider

2. Gemcitabine & capecitabine (mOS 28m)

Or

3. Gemcitabine alone (mOS 25m)

Question 13

What did the LAP07 trial look at?

Answer 13

CRT v gemcitabine alone

No OS benefit for CRT but improved PFS and local control.

Question 14

What chemotherapy is given in chemoradiotherapy for pancreatic cancer?

Answer 14

Capecitabine 830mg/m2 BD mon-fri

SCALOP trial compared CRT with cap v gem. mOS 15.2m v 13.4m

Question 15

How do you treat locally advanced pancreatic cancer?

Answer 15

Induction chemotherapy

1. FOLFIRINOX preferred if fit enough - if responding/tolerating on scan at 3m then complete 6m treatment before offering CRT
2. Gemcitabine and capecitabine or SA gem
   - scan at 3m, consider chemorad if > stable disease, lesion <=5-6cm, adequate fitness, no duodenum involvement

Question 16

What is the dose and fractionation of CRT for locally advanced pancreatic cancer?

Answer 16

50.4Gy in 28# over 5.5 weeks with capecitabine 830mg/m2 BD mon - fri

Consider renogram prior to treatment

Question 17

What is the SOC in metastatic disease?

Answer 17

1st line FOLFIRINOX (if PS 0-1), mOS 11.1m (v 6.8m for gemcitabine) RR 32% (v 9.4%)

If not fit for above;
Gemcitabine/abraxane (mOS 8.5m v 6.7m gem), RR 23%

2nd line:
Trials
Gem/cap if received FOLFIRINOX 1st line

Question 18

What should all patients be offered?

Answer 18

Enteric coated pancreatin