Pancreatic Cancer Flashcards
What are the two main types of pancreatic cancer?
1) exocrine (99%)
2) neuroendocrine (1%)
In which patient demographic is pancreatic cancer most common?
Males over the age of 60
Give 8 risk factors for pancreatic cancer:
1) smoking
2) high alcohol intake
3) chronic pancreatitis
4) high coffee intake
5) diabetes
6) excessive use of aspirin
7) family history
8) associated mutations
Give 2 genetic mutations associated with increased risk of pancreatic cancer:
1) PRSS-1
2) BRCA-2
What type of tumours are seen in exocrine pancreatic cancer?
Adenocarcinoma
Where in the pancreas is tumour formation most common?
head
Describe the pathogenesis of pancreatic cancer: (3)
- Accumulation of gene mutations lead to pancreatic intraepithelial neoplasia (panIN)
- this panIN progresses to an invasive carcinoma through the accumulation of mutations
- once the tumour is large enough, it can compress the bile duct, resulting in obstructive jaundice
Give 4 genetic mutations that are commonly seen in pancreatic intraepithelial neoplasia:
1) KRAS
2) CKDN2A
3) p53
4) SMAD
Give 4 organs that pancreatic cancer commonly metastasises to:
- Liver
- Peritoneum
- lungs
- bones
What is the average survival time for pancreatic cancer?
6 months
What are the two most indicative clinical features of pancreatic cancer?
1) obstructive jaundice symptoms
2) weight loss
Give 4 symptoms of obstructive jaundice:
1) yellow skin and sclera
2) pale stools
3) dark urine
4) generalised itching
Give 6 general symptoms of pancreatic cancer:
1) abdominal pain that may radiate to the back
2) anorexia and weight loss
3) palpable mass in the epigastric region
4) change in bowel habit
5) nausea or vomiting
6) new-onset diabetes or worsening of type 2 diabetes
Give two named signs associated with pancreatic cancer:
1) Courvoisier’s sign
2) Trousseau’s sign of malignancy
What is Courvoisier’s sign?
palpable gall bladder caused by an obstructed bile duct seen in pancreatic cancer
What is Trousseau’s sign of malignancy?
recurring thrombophlebitis (where blood vessels become inflamed with an associated thrombus in the area) which reoccurs in multiple locations over time
Give the NICE guidelines for pancreatic cancer referral:
1) over 40 with jaundice -> 2 week wait referral
2) over 60 with weight loss and any of diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation or new onset diabetes -> direct access CT abdomen
What two methods are used to diagnose pancreatic cancer?
- Imaging
- Histology via biopsy
What is CT TAP?
full CT including thorax, abdomen and pelvis
Name 3 imaging techniques for pancreatic cancer:
1) CT TAP
2) magnetic resonance cholangio-pancreatography (MRCP)
3) transabdominal ultrasound
Name 2 biopsy techniques used in pancreatic cancer?
- endoscopic retrograde cholagnio-psncreatography
- Percutaneous biopsy
What tumour marker is found raised in pancreatic cancer?
CA 19-9
What is the % 5 year survival rate for pancreatic cancer?
3%
Name 3 surgeries used to treat small and localised pancreatic cancers:
- Total pancreatectomy
- Distal pancreatectomy
- Whipple’s procedure
What is the full name given to Whipple’s procedure?
pancreaticoduodenectomy
What is the full name given to modified Whipple’s procedure?
pylorus-preserving pancreaticoduodenectomy (PPPD)
Name 6 structures structures removed in Whipples’s procedure:
1) head of pancreas
2) pylorus of the stomach
3) duodenum
4) gall bladder
5) bile duct
6) relevant lymph nodes
Give 5 examples of palliative care used in pancreatic cancer:
1) stents to relieve biliary obstruction
2) surgery to relieve symptoms e.g. bypass for obstruction
3) palliative chemotherapy
4) palliative radiotherapy
5) end of life care e.g. pain management
What cells do neuroendocrine pancreatic tumours arise from?
Islet of Langerhands
Which pancreatic cells produce glucagon?
Alpha cells
What pancreatic cells produce insulin?
beta cells
What pancreatic cells produce somatostatin?
Delta cells
What is somatostatin?
An inhibitory compound which suppresses the release of other gut hormones and decreases GI function
What are PP (F or Y) cells?
They produce pancreatic polypeptide, which regulates pancreatic secretions and may play a role in producing feelings of satiety
What do epsilon cells produce?
Ghrelin which triggers the feeling of hunger
What do G cells produce?
Gastrin - stimulates gastric acid secretion and gastric mobility
What other medical conditions has pancreatic cancer been linked with?
diabetes mellitus (especially if on gliclazide) – 2x risk
chronic pancreatitis – 3x risk
hereditary pancreatitis – 50x risk
gallstones – 1.25x risk
previous cholecystectomy – 1.23x risk
previous gastrectomy – 6x risk
chronic infections – hepatitis B, H.pylori, chronic dental problems
pretty much any other cancer – this may indicate shared causative risk factors or the effects of chemoradiotherapy leading to a secondary malignancy
Where in the pancreas do tumours lie?
65% head/neck of the pancreas – these tend to present earlier with obstructive jaundice
15% body/tail of the pancreas – these tend to present later and have a worse prognosis
15% diffuse or multicentric involvement of the whole pancreas
What are the 4 types of solid exocrine tumours?
1.90% pancreatic ductal adenocarcinoma: subtypes of this include mucinous non-cystic carcinoma, adenosquamous carcinoma, giant cell carcinoma and anaplastic carcinoma
- 5% acinar cell carcinoma
- <1% pancreatoblastoma: these are very rare embryonal tumours, which tend to present as a large abdominal mass in children aged 1-15 years
- <5% other solid tumours: these would include lymphomas, teratomas, and metastases from other sites e.g. GI tract, kidneys, lung, breast and melanoma
What are 3 types of cystic exocrine tumours?
- cystadenocarcinoma: these may be subclassified as mucinous or serous
- intraductal papillary-mucinous neoplasm (IPMN): these are derived from the pancreatic ducts and may cause either localised cancer or diffuse malignant change throughout the pancreas
- pseudopapillary carcinoma
What is the breakdown of endocrine tumours that are functional and non-functional?
one-third are non-functional – up to 90% of these are malignant, and as they do not cause hormonal symptoms they tend to present late with a large mass and/or metastatic disease
some of these may produce pancreatic polypeptide, which helps with making the diagnosis but does not actually cause symptoms
two-thirds are functional – overall about 50% of these are malignant, and they can cause a variety of symptoms and syndromes depending on which hormone they produce
What are insulinomas?
An insulinoma is a rare type of pancreatic tumor that produces excess insulin
insulinomas cause Whipple’s triad of symptomatic fasting hypoglycaemia which is relieved by glucose administration
What are glucagonomas?
Glucagonoma is a type of functioning NET that produces glucagon, a hormone that regulates blood sugar
glucagonomas cause diabetes, weight loss and paraneoplastic phenomena such as thrombophlebitis migrans and nail changes
Give 6 presentations associated with glucagonomas:
1) weight loss
2) diabetes
3) DVTs
4) anaemia
5) necrolytic dermatitis
6) hypalbuminaemia
What are gastrinomas?
gastrinomas cause Zollinger-Ellison syndrome, which is characterised by complex refractory peptic ulcer disease relieved by PPI administration, along with diarrhoea/steatorrhoea
Give the key presentation associated with a pancreatic gastrinoma:
duodenal ulcer disease
What are VIPomas?
vasoactive intestinal polypeptide
Verner-Morrison syndrome, which consists of severe watery diarrhoea leading to weight loss, hypovolaemia and electrolyte imbalances, as well as nausea, flushing and cramps
Give 3 presentations associated with VIPomas?
1) watery diarrhoea
2) hypokalaemia
3) metabolic acidosis
Give 3 presentations associated with somatostatinomas:
1) diabetes
2) gallstones
3) steatorrhoea (excess fat in stools)
Give the key presentation associated with insulinomas:
hypoglycaemia
Give 3 broad treatment groups used to manage neuroendocrine pancreatic tumours:
1) surgical removal
2) hormone analogues
3) chemotherapy
