Pancreatic Cancer

Question 1

Why does pancreatic cancer have poor prognosis?

Answer 1

Often diagnosed very late

5 year survival 25%

Question 2

What are the majority of pancreatic cancers?

Answer 2

Adenocarcinomas

Question 3

Where do most pancreatic cancers occur?

Answer 3

Head of the pancreas, can compress bile ducts causing obstructive jaundice

Question 4

What is the average survival of pancreatic cancer when diagnosed with advanced disease?

Answer 4

6 months

Pancreatic cancers metastasise early and spread particularly to the liver, peritoneum, lungs and bones

Question 5

How does pancreatic cancer present?

Answer 5

Painless obstructive jaundice

Yellow skin and sclera
Pale stools
Dark urine
Generalised itching

Question 6

What are some vague presenting symptoms of pancreatic cancer?

Answer 6

Non-specific upper abdominal or back pain
Unintentional weight loss
Palpable epigastric mass
Change in bowel habit
Nausea
New-onset diabetes or worsening of type 2 diabetes

Question 7

What are the NICE guidelines for suspected pancreatic cancer?

Answer 7

Over 40 with jaundice- 2 week wait referral

Over 60 with weight loss + vague symptom- direct access CT abdomen

Only case where GPs can refer directly for CT scan

Question 8

What are the named signs of pancreatic cancer?

Answer 8

Courvoisier’s law
Palpable gallbladder with jaundice likely to be cholangiocarcinoma or pancreatic cancer

Trousseau’s sign of malignancy
Migratory thrombophlebitis, sign of pancreatic adenocarcinoma

Inflammation of blood vessels, clot forms in local area which occurs in different areas over time

Question 9

What investigations are used for pancreatic cancer?

Answer 9

Staging CT

CA19-9

MRCP

ERCP

Biopsy

Question 10

How is pancreatic cancer managed?

Answer 10

• Surgery to remove tumour (if isolated to head, 10%)
• Total pancreatectomy
• Distal pancreatectomy
  -Pylorus-preserving pancreaticoduodenectomy (PPPD, modified Whipple procedure)
• Radical pancreaticoduodenectomy

Question 11

What is done in palliative treatment of pancreatic cancer?

Answer 11

Stents
Surgery to improve symptoms
Palliative chemotherapy and radiotherapy
End of life care with symptom control

Question 12

What is a Whipple Procedure?

Answer 12

Removal of a tumour of the head of the pancreas that has not spread

Massive operation, patients need good baseline health

Question 13

What is removed in a Whipple Procedure?

Answer 13

Head of the pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Lymph nodes

Modified Whipple preserves the pylorus