Pancreatic cancer Flashcards
Describe the structure and location of the pancreas
- Retroperitoneal organ extending from the second part of the duodenum to the spleen
- The pancreatic duct joins the common bile duct to form the ampulla of Vater which joins the duodenum
What are the functions of the pancreas?
- Exocrine: secretes lipase, amylase and proteases which are responsible for digestion of fat, carbohydrate and protein. The enzymatic secretion is influenced by gut hormones.
- Endocrine: secretes insulin, glucagon and somatostatin – hormones involves in regulation of glucose storage and use.
What is pancreatic cancer?
Malignancy arising from the exocrine or endocrine tissues of the pancreas
What are the different types of pancreatic cancer?
95% of tumours affect the exocrine glands, usually in the head & neck or tail:
- Ductal carcinoma (cancer of the epithelial cells lining the ducts- poor prognosis)
- cystic tumours, ampullary cell tumours and islet cell tumours- better prognosis
- Cancer of the acinar cells (5% cases, produce digestive enzymes)
Describe the epidemiology of pancreatic cancer
- Increasing incidence: 8-12/100,000
- 2 x more common in MALES
- Peak age: 60-80 yrs
explain the aetiology/ risk factors for pancreatic cancer?
- UNKNOWN
- 5-10% are hereditary (e.g. MEN, HNPCC, FAP, Von-Hippel Lindau syndrome)
- 75% occur within head or neck of pancreas. 15-20% occur in body and 5-10% in tail
- Risk Factors:
- Age >65
- male
- African american
- Smoking
- Alcohol
- Obesity
- Diabetes mellitus
- Chronic pancreatitis
- Liver cirrhosis
- Dietary (low intake of fresh fruit and vegetables, high fat and red/processed meat)
- Inc waist circumference
- Family history (inherited mutations in BRCA2, PALB2)
What are the presenting symptoms of pancreatic cancer?
- Initial symptoms are often NON-SPECIFIC: Nausea, vomiting, fatigue
Pancreatic cancer is commonly painless jaundice and unexplained weight loss. Other signs and symptoms include loss of appetite, fatigue and dark urine. The presentation may vary depending on the location of the tumour.
Other symptoms:
- Anorexia or weight loss
- Steatorrhea (due to malabsorbtion)
- Malaise
- Epigastric pain – radiates to back (due to invasion of coeliac plexus) and relieved by sitting forward (75% of tumours in body and tail present with this)
- Diabetes mellitus (loss of pancreatic exocrine func)
- Jaundice (tumours of head usually present with this)
What signs of pancreatic cancer can be found on physical examination?
- Weight loss
- Cachectic & malnourished
- Epigastric tenderness or mass
- Jaundice and a palpable gallbladder (Courvoisier’s law - a palpable gallbladder with painless jaundice is unlikely to be due to gallstones)
- Scleral icterus (yellowing of the eyelids)
- If metastatic spread –> hepatomegaly/splenomegaly/lymphadenopathy
- Trousseau’s Sign of Malignancy - superficial thrombophlebitis (blood clots can be felt as small spots under the skin)
Describe the use of lab findings in the diagnosis of pancreatic cancer
Generally non- specific:
can see an increase in
- Serum amylase
- serum lipase
- CA19-9 antigen (helps with immune surveillance)
- CEA (glycoprotein involved in cell adhesion)
- Obstructive jaundice can lead to an increase in: bilirubin, alkaline phosphatase, transaminase
(BUT these may be elevated in people without cancer, esp smokers); CANNOT BE USED FOR DIAGNOSIS
What investigations are used to monitor pancreatic cancer?
- First line:
- LFTs (liver function tests)- although non-specific
- abdo USS - Bloods:
- FBC (anaemia, thrombocytopenia)
- CA 19-9 and CEA are tumour markers – both will be elevated with CA-19 being more specific, but neither are diagnostic
- Can cause obstructive jaundice:
*High bilirubin
*High Alkaline phosphatase
*Deranged clotting - Imaging – can show pancreatic mass +/- dilated biliary tree +/- hepatic metastases:
- Endoscopic ultrasound (high sensitivity for pancreatic cancer) + biopsy
- CT with/without guided biopsy
- MRI/MRCP
- ERCP - may allow biopsy, bile cytology and stenting
How are pancreatic cancers staged?
Staging depends on:
SIZE + LOCATION
(1) less than 2 cm
(2) greater than 2 cm
(3) grown into neighboring tissue
(4) METASTATIC- spreads through blood & lymph
determine if resectable
what are the treatment options for pancreatic cancers?
- Chemotherapy:
a. Neoadjuvant therapy (shrink tumour before surgery)
b. Adjuvant therapy (after surgery)
c. Chemotherapy alone is typically used for patients with advanced or metastatic pancreatic cancer who are not candidates for surgical resection. Can provide symptom relief- not the first-line management for potentially resectable tumours. - Radical resection- Whipple’s procedure: pancreatic duodenectomy - curative
- Criteria for resection: no evidence of involvement of SMA or coeliac arteries
- No evidence distant metastasis
- several organs share blood supply; gall bladder, parts of the duodenum, jejenum and stomach are also removed - 5-Fluorouracil- recommended after surgery
- FOLFIRINOX regime- for metastatic disease
What are some complications associated with treatments used for pancreatic cancer?
Surgical:
- pancreatic leaks and fistula
- early delayed gastric emptying
- Duodenal obstruction
- Cholangitis
- DVT/PE
- Bleeding
- DIC (Disseminated intravascular coagulation)
- Malignant ascites
Describe the prognosis for pancreatic cancer
- Poor prognosis (5 year survival < 5%), too advanced by the time of diganosis
- Median survival all patients after diagnosis = 4-6 months (low)
- In patients able to undergo a successful curative resection the median survival ranges from 12 to 19 months, and the 5-year survival rate is 15–20%.
- Patients with periampullary and endocrine tumours have a better prognosis.
- Often metastasis at time of presentation
- Direct invasion of local structures usually involve: spleen, transverse colon & adrenal glands
- Lymphatic metastasis: regional lymph nodes, lungs, liver, peritoneum
