Pancreatic Cancer

Question 1

Aetiology of pancreatic cancer

Answer 1

Primary pancreatic ductal adenocarcinoma (>85% of all pancreatic neoplasms)
May also be adenosquamous, mucinous cystadenocarcinomas. Endocrine tumours include insulinomas, glucagonomas gastrinomas

75% within the head or neck of the pancreas (presents as a periampullary tumour), 15-20% in the body and 5-10% in the tail. Spread is local and to the liver

5-10% inherited
- Hereditary pancreatitis
- Peutz-Jeghers syndrme
- Familial atypical multiple mole melanome
- HNPCC syndrome

Question 2

Risk factors for pancreatic cancer

Answer 2

Older age
Cigarette smoking
Family history
Hereditary non-polyposis colorectal carcinoma (HPNCC)
Multiple endocrine neoplasia
BRCA2 gene
Chronic sporadic pancreatitis
Obesity
Dietary factors e.g. high alcohol intake, high meat and fat, low serum folate levels

Question 3

Symptoms of pancreatic cancer

Answer 3

Jaundice (painless)
Light stools (obstructive jaundice
Steatorrhoea (loose, smelly stools) due to loss of exocrine function
Dark urine
Upper abdominal pain or discomfort
Weight loss and anorexia
Thirst, polyuria, nocturia (Diabetes)
Nausea, vomiting
Atypical back pain
Petechiae, purpura, bruising

Question 4

Signs of pancreatic cancer on examination

Answer 4

General exam
- Signs of weight loss
- Jaundice
Abdominal exam
- Epigastric tenderness or mass
- Palpable gallbladder (Courvoisier’s law)
- Hepatomegaly (metastatic spread)
- Trousseau’s sign of malignancy - superficial thrombophlebitis
- Migratory thrombophlebitis

Question 5

Investigations for pancreatic cancer

Answer 5

1. Pancreatic protocol CT then drain the bile duct
   
   2. FDG-PET/CT and/or endoscopic US (EUS) with guided tissue sampling
   3. Consider biliary brushing for cytology if:
      a. ERCP is used to relieve biliary obstruction
      b. No tissue diagnosis

CA 19-9: raised
LFTs: cholestatic (Raised ALP + GGT)
U&Es: hypoCa
FBC: Anaemia, thrombocytopenia
Clotting: prolonged PT

Direct access CT: visualise mass, “double duct” sign - simultaneous dilatation of the CBD and pancreatic duct
Abdo US: mass, dilated bile duct
Endoscopic US (EUS): diagnostic
FGD-PET: if diagnosis is unclear
ERCP with brushing: ampullary tumour
MRCP: ?duct involvement

Question 6

Referral for suspected pancreatic cancer

Answer 6

> 40yo with jaundice → 2ww
2ww Urgent direct access CT or urgent US for >60yo + weight loss AND:
- Diarrhoea
- Back pain
- Abdo pain
- Vomiting
- Constipation
- New onset diabetes

Question 7

Management for pancreatic cancer

Answer 7

pancreatic multidisciplinary team
Supportive

1. Relieve any biliary and duodenal obstruction: Offer resectional surgery (resectable pancreatic cancer + obstructive jaundice + well enough)
2. Neoadjuvant therapy
   - ONLY for those with BORDELRINE resectable pancreatic cancer as part of a clinical trial
3. Surgery: Consider pylorus-preserving resection - Whipple’s resection (pancreaticoduodenectomy)
   - Consider standard lymphadenectomy
4. Adjuvant treatment
   - 6 cycles of gemcitabine + capecitabine

Non-resectable → systemic combo chemo with FOLFIRINOX
Palliative: ERCP with stenting

Question 8

What is the supportive management for pancreatic cancer

Answer 8

Pain management: EUS-guided percutaneous neurolytic coeliac plexus block
Psychological support
Nutritional management:
- Enteric-coated pancreatin
VTE prophylaxis: aspirin 75/150mg or LMWH

Question 9

What is the screening programme for pancreatic cancer

Answer 9

Surveillance for pancreatic cancer is offered to people:
- Hereditary pancreatitis and PRSS1 mutation
- BRCA1, BRCA2, PALB2 or CDKN2A (p16) mutations, and one or more first-degree relatives with pancreatic cancer
- Peutz–Jeghers syndrome

Consider in people with:
- 2 or more first-degree relatives with pancreatic cancer, across 2 or more generations
- Lynch syndrome (mismatch repair gene [MLH1, MSH2, MSH6 or PMS2] mutations) and any first-degree relatives with pancreatic cancer.

Question 10

Complications of a Whipple’s resection

Answer 10

Pancreatic leaks
Intra-abdominal sepsis → Dumping syndrome
- AKA rapid gastric emptying, food moves very quickly from the stomach to the small bowel
-diarrhoea, nausea, and feeling light-headed or tired after a meal
Peptic ulcer disease
DVT and PE

Question 11

Complications of pancreatic cancer

Answer 11

Duodenal obstruction (abdo pain, vomiting, absolute constipation)
Cholangitis (Fever, jaundice, RUQ pain)
DVT and PE
Ulceration into the duodenum → bleeding

Question 12

Prognosis for pancreatic cancer

Answer 12

Poor prognosis
5 year survival rate 8.5%
At the time of diagnosis, 10-15% have resectable disease, About 30%-35% present with locally advanced pancreatic cancer
Overall median survival from diagnosis in Europe was 4.6 months
Strongest prognostic indicators for long-term patient survival: negative resection margins, tumour DNA content, tumour size, and absence of lymph node metastases
Patients with metastatic disease (50% to 55%) have a limited survival of only 3 to 6 months