Pancreatic Cancer Flashcards
List 4 risk factors for pancreatic cancer
- Smoking
- Chronic pancreatitis
- Family history
- Late onset diabetes mellitus
- Lynch Syndrome
What is a key presenting feature that should make you immediately consider pancreatic cancer?
List a ddx for this feature
Painless obstructive jaundice
Key differential is cholangiocarcinoma
What causes Painless obstructive jaundice?
When a tumour at the head of the pancreas compresses the bile ducts, blocking the flow of bile out of the liver
How does Painless obstructive jaundice present?
- Yellow skin and sclera
- Pale stools
- Dark urine
- Generalised itching
List 4 other symptoms for pancreatic cancer
(Hint: they are vague)
- Non-specific upper abdominal or back pain
- Unintentional weight loss
- Palpable mass in the epigastric region
- Change in bowel habit
- Nausea or vomiting
List 4 other signs of pancreatic cancer
(Hint: they are vague)
- Palpable mass in the epigastric region
- Cachectic patient
- Jaundice
- Palpable mass
- Hepatomegaly
- Ascites
What sign specifically related to diabetes, may indicate pancreatic cancer?
New onset of diabetes, or worsening glycaemic control despite good lifestyle measures and medication
What are the NICE criteria on when to refer for suspected pancreatic cancer?
- > 40 + jaundice – 2 week wait referral
- > 60 + weight loss + an additional symptom – referred for a direct access CT abdomen
Additonal symptoms: Diarrhoea, back pain, abdo pain, nausea, vomiting, constipation, new‑onset diabetes
What is the only scenario where GPs can refer directly for a CT scan?
Suspected pancreatic cancer
What is Courvoisier’s law?
States that a palpable gallbladder along with jaundice is unlikely to be gallstones
The cause is usually cholangiocarcinoma or pancreatic cancer
What is Trousseau’s sign?
Migratory thrombophlebitis as a sign of malignancy, esp adenocarcinoma.
- Thrombophlebitis → inflammation of BVs with an associated thrombus in that area
- Migratory → thrombophlebitis reoccurring in different locations over time
95% of pancreatic cancers are _________ and arise from _________ cells. These have a _________ prognosis
Less than 5 % of pancreatic tumours arise from _________ cells and are known as called a _________ tumours.
adenocarcinomas, exocrine, worse, endocrine, neuroendocrine
Compare a functional vs Non Functioning neuroendocrine tumour (NET)
Functional → release hormones ie. Gastrinoma, Insulinoma
Non Functioning → Carcinoid releases serotonin (5-HT) or its precursor (5-HTP) often arise elsewhere in body and metastasise to pancreas
Insulinomas arise from what cell type?
What is the Whipple Triad?
Beta cell
Whipple Triad:
- Symptoms of hypoglycaemia
- Low plasma glucose
- Rapid relief of symptoms with glucose administration
What cell type do Glucagonomas arise from?
What is meant by its 4D Syndrome?
alpha Cells
4D Syndrome: Dermatitis, Diabetes, DVT, Depression
What do VIPomas secrete?
What syndrome does it present with?
VIP (vasoactive intestinal peptide)
WHDA Syndrome: Watery Diarrhoea, Hypokalaemia Achlorhydria
How does Zollinger Ellison Syndrome (gastroma) present?
What would be seen on endoscopy?
Presents: abdo pain, diarrhoea, heartburn
Endoscopy: severe peptic ulceration
From which cells do Somatostatinoma arise?
With which syndrome do these present?
Delta cells
Inhibitory Syndrome: Diabetes, Steatorrhoea, Cholilithiasis
List 2 other pancreatic tumours
- Serous Cystadenomas - benign
- Mucinous cystic neoplasms of the pancreas
- Intraductal Papillary Mucinous Neoplasms (IPMN)
What is the initial imaging for suspected pancreatic cancer?
What may/may not be seen
Abdominal USS → may demonstrate a pancreatic mass or a dilated biliary tree
- Not good in early disease but hepatic metastases and ascites may be seen in late stage disease
- Tail /body of pancreas often obscured by gas and hence not seen
What may blood tests show in pancreatic cancer?
FBC - anaemia or thrombocytopenia
LFTs - ↑ bilirubin, ALP, and GGT
What is the gold standard investigation for diagnosis of pancreatic cancer?
What sign may be seen?
High-resolution CT scan
May demonstrate the ‘double duct’ sign - presence of simultaneous dilatation of the CBD and PDs
What tumour marker may be raised in pancreatic cancer?
When is this marker used clinically
CA 19-9
Used clinically for assessing response to treatment rather than for initial diagnosis as it is raised in a number of conditions (ie. cholangiocarcinoma)
What is the role of MRCP and ERCP in suspected pancreatic cancer?
MRCP - to assess biliary system in detail to assess the obstruction
ERCP - to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour
What investigation may assist in staging pancreatic cancer?
CT thorax, abdomen and pelvis (CT TAP) for staging and to look for metastasis and other cancers
What surgical options are available for pancreatic cancer?
- Total pancreatectomy
- Distal pancreatectomy
- Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
- Radical pancreaticoduodenectomy (Whipple procedure)
Only considered with small tumours isolated in the head of the pancreas (10% of cases)
List 4 palliative treatments for pancreatic cancer
- Stents to relieve biliary obstruction
- Surgery to improve symptoms (e.g. bypassing the biliary obstruction)
- Palliative chemo or radiotherapy (to improve symptoms and extend life)
- End of life care with symptom control
Briefy explain a Whipple Procedure (pancreaticoduodenectomy)
A surgical procedure to remove a tumour of the head of the pancreas that has not spread. It involves removal of the:
- Head of the pancreas
- Pylorus of the stomach
- Duodenum
- Gallbladder
- Bile duct
- Relevant lymph nodes
