Pancreatic Cancer

Question 1

A 58 year old man presents with painless progressive jaundice for 2 weeks. Investigations reveal cholestatic liver function tests, dilated bile ducts, and a 3cm mass in the head of the pancreas. How would you manage him?

Answer 1

Impression
Given HOP mass, this is most likely a head of pancreas tumour. This is most likely a ductal adenocarcinoma Some differentials I would consider include;
- other malignancy: cholangiocarcinoma, ampullary carcinoma, Zollinger-Ellison syndrome, islet cell cancer
- rare: IGG4 disease (autoimmune pancreatitis which can cause pancreas masses)

Would want to assess for and prevent complications of this presentation including biliary obstruction, cholangitis and subsequent sepsis, as well as coagulopathies secondary to hepatic dysfunction

Question 2

Pancreatic cancer - Hx and Ex

Answer 2

History

• sx: jaundice, dark urine, pale stools, cachexia, diarrhoea
• RISK: fam hx, smoking, advanced age, male gender
• features of mets: bone pain, haemoptysis, seizure/neuro sx
• PMHx, PSHx, medications, SNAP

Examination

• general obs + vital signs
• abdominal exam: peripheral stigmata, jaundice, abdo mass, +/- pain
• systems review in consideration of metastasis

Question 3

Pancreatic cancer - Investigations

Answer 3

Investigations

• Bloods: LFT, UEC, FBC, tumour markers (CA19.9, CEA)
• Imaging: Abdo U/S, MRCP, ERCP, percutaneous transhepatic cholangiography, staging imaging (CT CAP, PET)
• diagnostic: endoscopic US and biopsy of HOP for histopathological analysis (gold standard)

Question 4

Pancreatic cancer - Management

Answer 4

Management
Key principles:
- assemble MDT including medical oncology, gen surg, social work, etc
- referral to upper GI surgeon

Diagnostic investigations:
- EUS and tissue biopsy of HOP, necessary for determining the exact sub-type of cancer before proceeding with management

Supportive/palliative:

• Nutritional support for malnourishment
• Vit K (not absorbing fat-soluble vitamins
• involvement of pal care nursing
• biliary decompression (stenting/shunting)
• electrolytes and fluids
• palliative care referral

Definitive

• Whipples procedure (pancreaticoduodectomy
• +/- neoadjuvant chemotherapy
• pain management once more advanced