Pancreatic cancer Flashcards
Why has pancreatic cancer got a poor prognosis and where do most of them occur?
-The vast majority are adenocarcinomas, and most occur in the head of the pancreas
-Once a tumour in the head of the pancreas grows large enough it can compress the bile ducts, resulting in obstructive jaundice.
Pancreatic cancers tend to spread and metastasise early, particularly to the liver, then to the peritoneum, lungs and bones.
The average survival, when diagnosed with advanced disease, is around 6 months.
When caught early, the cancer is isolated to the pancreas and surgery is possible, the 5-year survival is still around 25% or less.
How does pancreatic cancer present?
Painless obstructive jaundice. This occurs when a tumour at the head of the pancreas compresses the bile ducts, blocking the flow of bile out of the liver. It presents with:
Yellow skin and sclera
Pale stools
Dark urine
Generalised itching
The other presenting features for pancreatic cancer can be vague:
Non-specific upper abdominal or back pain
Unintentional weight loss
Palpable mass in the epigastric region
Change in bowel habit
Nausea or vomiting
New-onset diabetes or worsening of type 2 diabetes
When do you refer someone?
Over 40 with jaundice – referred on a 2 week wait referral
Over 60 with weight loss plus an additional symptom (see below) – referred for a direct access CT abdomen
The NICE guidelines suggest a GP referral for a direct access CT abdomen or ultrasound to assess for pancreatic cancer if a patient has weight loss plus any of:
Diarrhoea
Back pain
Abdominal pain
Nausea
Vomiting
Constipation
New-onset diabetes
What is Courvoisier’s law?
A palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.
What is Trousseau’s sign of malignancy?
migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma. Thrombophlebitis is where blood vessels become inflamed with an associated blood clot (thrombus) in that area. Migratory refers to the thrombophlebitis reoccurring in different locations over time.
Investigations?
Imaging (usually CT scan) plus histology from a biopsy.
Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers.
CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in pancreatic cancer. It is also raised in cholangiocarcinoma and a number of other malignant and non-malignant conditions.
Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction.
Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.
Biopsy may be taken through the skin (percutaneous) under ultrasound or CT guidance, or during an endoscopy under ultrasound guidance.
Management (surgery) ?
-hepatobiliary (HPB) MDT meeting.
-Surgery to remove the tumour is more likely to be considered with small tumours isolated in the head of the pancreas (about 10% of cases):
-Total pancreatectomy
-Distal pancreatectomy
-Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
-Radical pancreaticoduodenectomy (Whipple procedure)
Management (not surgery) ?
-Stents inserted to relieve the biliary obstruction
-Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
-Palliative chemotherapy (to improve symptoms and extend life)
-Palliative radiotherapy (to improve symptoms and extend life)
-End of life care with symptom control
Describe the whipple procedure
Removal of the
Head of the pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Relevant lymph nodes
A modified Whipple procedure involves leaving the pylorus in place. It is also known as a pylorus-preserving pancreaticoduodenectomy (PPPD).
