Pancreatic Cancer

Question 1

What is the most common type of pancreatic cancer?

Answer 1

Adenocarcinoma

Question 2

Where does most pancreatic cancers occur?

Answer 2

In the head of the pancreas (as opposed to the body and tail)

Question 3

Why is the prognosis for pancreatic cancer so poor?

Answer 3

• often diagnosed late
• spread and metastasise early

Question 4

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

Answer 4

Around 6 months

Question 5

What is the key presenting feature that should make you immediately consider pancreatic cancer?

What is the key differential?

Answer 5

Painless obstructive jaundice

The key differential is cholangiocarcinoma)

Question 6

What are some risk factors for pancreatic cancer?

Answer 6

• increasing age
• smoking
• diabetes
• chronic pancreatitis
• multiple endocrine neoplasia (MEN)
• BRCA2 gene

Question 7

Clinical features of pancreatic cancer?

Answer 7

• painless jaundice
• steatorrhoea (loss of exocrine function)
• dark urine
• loss of endocrine function e.g. diabetes
• atypical back pain
• non-specific e.g. anorexia, weight loss, epigastric pain, generalised itching

Question 8

Tip

Answer 8

It is worth noting that a new onset of diabetes, or a rapid worsening of glycaemic control type 2 diabetes, can be a sign of pancreatic cancer.

Keep pancreatic cancer in mind if a patient in your exams or practice has worsening glycaemic control despite good lifestyle measures and medication.

Question 9

How does pancreatic cancer cause painless obstructive jaundice?

Answer 9

This occurs when a tumour at the head of the pancreas compresses the bile ducts, blocking the flow of bile out of the liver.

Question 10

What is the referral criteria for pancreatic cancer?

Answer 10

≥40 y/o with jaundice –> 2ww referral

≥60 with weight loss PLUS an additional symptom –> refer for a direct access CT abdomen

Question 11

When is a GP referral for a direct access CT abdomen (or ultrasound if not available) indicated to assess for pancreatic cancer?

Answer 11

Patient is >60 y/o with weight loss plus any of the following:

• Diarrhoea
• Back pain
• Abdominal pain
• Nausea
• Vomiting
• Constipation
• New-onset diabetes

Question 12

When is the only scenario where GPs can refer directly for a CT scan?

Answer 12

In suspected pancreatic cancer

Question 13

What is Courvoisier’s law?

Answer 13

This states that a a palpable gallbladder along with jaundice is UNLIKELY to be gallstones.

The cause is usually cholangiocarcinoma or pancreatic cancer.

Question 14

What is Trousseau’s sign of malignancy?

Answer 14

Refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma.

Question 15

What is the investigation of choice in suspected pancreatic cancer?

Answer 15

High resolution CT

Question 16

What tumour marker may be raised in pancreatic cancer?

Answer 16

Ca 19-9 (also raised in cholangiocarcinoma)

Question 17

Role of MRCP vs ERCP in pancreatic cancer?

Answer 17

MRCP –> may be used to assess the biliary system in detail to assess the obstruction.

ERCP –> can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.

Question 18

What is a Whipple procedure (pancreaticoduodenectomy)?

Answer 18

A surgical operation to remove a tumour of the head of the pancreas that has not spread.

A Whipple procedure is a massive operation so patients need to be in good baseline health.

It involves the removal of the:
- Head of the pancreas
- Pylorus of the stomach
- Duodenum
- Gallbladder
- Bile duct
- Relevant lymph nodes

Question 19

What are 2 side-effects of a Whipple’s?

Answer 19

1) dumping syndrome

2) peptic ulcer disease

Question 20

What is dumping syndrome?

Answer 20

I.e. rapid gastric emptying

Occur when your stomach empties its contents too rapidly into your small intestine