Pancreatic cancer Flashcards
Define pancreatic cancer.
Malignancy arising form the endocrine or exocrine tissues of the pancreas.
Usually pancreatic ductal adenocarcinoma, (>85%) presenting with painless jaundice and weight loss.
What are the risk factors for pancreatic cancer?
Unknown cause
FH (10%) - hereditary syndromes include…
- BRCA2 mutation
- familial atypical multiple mole melanoa (CDKN2A)
- Peutz-Jeghers (STK11/LKB1)
- hereditary pancreatitis (PRSS1)
- MEN
- HNPCC
- FAP
- Gardner
- von Hippel-Lindau syndrome
What is the pathophysiology of pancreatic cancer?
- where do most occur
- where does it spread to
- what cell type do most pancreatic cancers affect
- 75% occur in head/neck of the pancreas (periampullary tumour)
- 15-20% occur in the body and 5-10% occur in the tail
- Spread is local and to the liver
- 80% adenocarcinomas, others adenosquamous, mucinous cystadenocarcinomas, or endocrine tumours (insulinomas, gucagonomas, gastrinomas)
Name 3 types of pancreatic cancer precursor lesions.
Precursor lesions include
- pancreatic intraepithelial neoplasia (PanIN)
- intraductal papillary mucinous neoplasm
- mucinous cystic neoplasm
What is the epidemiology of pancreatic cancer?
- Poor prognosis
- Cancer of old people - peak age 60-80years
- M>F 2:1
- 4th most common cause of cancer-related deaths in UK
What is the typical presentation of pancreatic cancer?
- Initial symptoms are non-specific - anorexia, malaise, weight loss, nausea.
- Later jaundice, epigastric pain.
Uncommon symptoms: thirst, polyuria, nocturia
What are the signs of pancreatic cancer on examination?
- Weight loss, epigastric tenderness or mass
- Jaundice and palpable gall bladder (Courvoisier’s law)
- Hepatomegaly (if metastatic spread)
- Trousseau’s sign is associated with superficial thrombophlebitis
- Other: petechiae, purpura, bruising (DIC in advanced disease)
What investigations would you do for pancreatic cancer?
Diagnosis:
- Abdo USS - may show pancreatic mass or dilated biliary tree
- CT imaging - GOLD standard for diagnosis and prognosis/ staging
- PET-CT/MRCP - if diagnosis unclear
- CT CAP - staging
- Endoscopic ultrasound +/- FNA - for tissue biopsy staging
Other:
- Tumour markers CA19-9, CEA - high but neither diagnostic
- High bilirubin, high ALP, high GGT - if obstructive jaundice
- Deranged clotting - high PT
- FBC - low platelets in DIC, anaemia in GI bleed
- Staging laparoscopy - identified peritoneal, capsular or serosal involvement or small hepatic metastases not seen on CT
What tumour marker is associated with pancreatic cancer? What is its use?
CA19-9 is a tumour marker for pancreatic carcinoma
- High sensitivity and specificity
- Main role is in assessing response to treatment
Which of these are true about pancreatic cancer? (3)
- Cigarette smoking is a risk factor
- Diabetes is a risk factor
- Tumours are most common in the tail of the duct gland.
- Encasement of the superior mesenteric vessels does not preclude surgery
- Most lesions arise from exocrine ductal epithelium
- In patients not suitable for surgery, a good response can be expected from chemoradiotherapy.
- Cigarette smoking is a risk factor
- Diabetes is a risk factor
- Most lesions arise from exocrine ductal epithelium
Few patients are suitable for surgery and vessel encasement is a contraindication. 1 year survival rates are very poor. Most tumours occur in the head of the gland.
What is the management of pancreatic cancer?
Pancreaticoduodenectomy with antrectomy (Whipple’s) +/- regional lymphadenectomy - if tumour at head of pancreas
Distal pancreatectomy +/- splenectomy with regional lymphadenectomy - for body or tail of pancreas tumours
Adjuvant chemotherapy - for all patients, prolongs survival
Other:
Pancreatic enzyme replacement - Creon
Internal biliary stenting - if obstructive symptoms >10days post-op
Analgesia
What is the prognosis with pancreatic cancer?
Stage I/II - only 10-15% have resectable disease and median survival is 15-19months
Stage III/unresectable - poor prognosis with chemo/radiotherapy only having a modest improvement in survival
Stage IV/metastatic - 3-6 month survival
What are the complications of pancreatic cancer?
- Cholangitis
- DVT
- PE
- Obstruction
- Surgery related: bleeding, pancreatic leaks, fistula, delayed gastric emptying
What is shown?
Pancreaticoduodenectomy