Pancreatic Cancer Flashcards
How common is pancreatic cancer relative to other cancers?
It is the tenth most common cancer in the UK
How common is death from pancreatic cancer, compared to other cancers?
It is the 5th most common cause of cancer death
What is the average age of diagnosis of pancreatic cancer?
60-65
Which gender is pancreatic cancer more common in?
Males before 75, women after 75
What is the only well established aetiological factors in the development of pancreatic cancer?
Smoking
By how much does smoking increase the risk of pancreatic cancer?
5x
What are some potential risk factors for pancreatic cancer?
- Alcohol
- Coffee
- Diabetes mellitus
- Chronic pancreatitis
What is the problem with alcohol and coffee as risk factors for pancreatic cancer?
Studies have been contradictory
What is the problem with diabetes mellitus and chronic pancreatitis as risk factors for pancreatic cancer?
Both may develop as a consequence of pancreatic cancer, so the results have been questioned
What are the types of pancreatic cancer?
- Adenocarcinoma of ductal origin
- Endocrine tumours arising from islet cells
- Acinar cell tumours
What % of cases of pancreatic cancer are adenocarcinomas of ductal origin?
90%
What % of cases of pancreatic cancer are endocrine tumours arising in islet cells?
5%
What % of cases of pancreatic cancer are acinar cell tumours?
5%
What proportion of pancreatic cancers occur in the head of the pancreas?
2/3
How do pancreatic tumours occurring in the head of the pancreas present?
- Epigastric pain
- Weight loss
- Jaundice
What proportion of pancreatic cancers occur in the tail and body of the pancreas?
1/3
How do pancreatic tumours occurring in the tail and body of the pancreas present?
- Pain in the left upper quadrant of abdomen
- Constipation
Why do pancreatic tumours occurring in the tail and body of the pancreas present with constipation?
Due to colonic involvement
What happens to the pain caused by pancreatic cancer of the tail or body over time?
It increases in severity and radiates to the back
What does the radiation of the pain caused by pancreatic cancer of the body or tail co-incidence with?
Retroperitoneal invasion
When does the pain from pancreatic cancer of the body or tail characteristically improve?
When the patient leans forwards
What has a better prognosis, pancreatic tumours of the head, or of the body or tail?
Of the head
Why do pancreatic tumours of the body or tail have a worse prognosis?
Because they tend to be larger at diagnosis, and therefore have a worse prognosis
When might pancreatic cancers cause obstructive jaundice at an early stage?
When they are periampullary
What is the result of periampullary pancreatic tumours causing obstructive jaundice at an early stage?
Can result in an earlier diagnosis, and therefore the tumours have a better outcome
Where might pancreatic tumours extend into?
- Duodenum
- Stomach
- Retroperitoneum
What do pancreatic tumours that present late often have involvement of?
Locoregional lymph nodes, particularly para-aortic and portal
What are the common sites of metastasis in pancreatic cancer?
- Liver
- Lung
When are many patients asymptomatic up until?
The common bile duct becomes blocked, and they become jaundiced
What are the rarer presentations of pancreatic cancer?
- Splenomegaly
- Varices
How can pancreatic cancer cause splenomegaly and varices?
Splenic vein occlusion by a tumour in the body or tail of the pancreas
What might be the presenting feature of pancreatic malignant months before any other signs or symptoms emerge?
Diabetes mellitus
What are the other presenting features of pancreatic cancer?
- Trousseau sign of malignancy
- Fever
- Ascites
What is Trousseau sign of malignancy?
Superficial migratory thrombophlebitis
What causes fever in pancreatic cancer?
Cholangitis
What causes ascites in pancreatic cancer?
Peritoneal involvement
What lymph nodes should be examined in pancreatic cancer?
- Neck
- Supraclavicular
- Axillary
- Paraaortic
What should be looked for on abdominal examination in pancreatic cancer?
- Mass in epigastrum
- Mass in left hypochondrium
- Visible peristalsis
- Bowel obstruction
- Abdominal distention
- Ascites
- Hepatomegaly
- Splenomegaly
Who should early pancreatic cancer be considered in?
Any individual with ongoing upper abdominal pain
What is investigation aimed at in pancreatic cancer?
- Establishing prognosis
- Defining operability
What kind of ultrasound is used in pancreatic cancer investigation?
Endoluminal ultrasound
What is the advantage of endoluminal ultrasound over abdominal ultrasound in pancreatic cancer?
It can produce clearer images
Why does endoluminal ultrasound produce clearer images in pancreatic cancer?
Because it is passed down the oesophagus, so achieves closer proximity to the pancreas
What can CT imaging reveal in pancreatic cancer?
- Mass
- Evidence of invasion
- Lymph node involvement
- Metastasis
Is ERCP required in pancreatic cancer?
Yes
What can be performed during ERCP in pancreatic cancer?
- Brushings
- Suction of the pancreatic duct
- Biopsy
- Stenting
What should failure to obtain a diagnosis by ERCP be followed by?
- Image-guided biopsy by FNA
- Laparoscopic biopsy or assessment
What blood tests should be done in pancreatic cancer?
- FBC
- Renal and liver funtion
- Serum CA19-9
What staging system is used in pancreatic cancer?
TNM
How can pancreatic cancer be grouped practically?
If it resectable, locally advanced (non-resectable), or metastatic at presentation
What is Tis in pancreatic cancer?
Carcinoma in situ
What is T1 in pancreatic cancer?
Tumour has not spread beyond the pancreas, and is smaller than 2cm
What is T2 in pancreatic cancer?
Tumour has not spread beyond the pancreas, but is larger than 2cm
What is T3 in pancreatic cancer?
Tumour has spread from the pancreas to surrounding tissues near the pancreas, but not to major blood vessels or nerves
What is T4 in pancreatic cancer?
Tumour has extended beyond the pancreas and invades nearby large blood vessels or nerves
What is N0 in pancreatic cancer?
Regional lymph nodes are not involved
What is N1 in pancreatic cancer?
Regional lymph nodes are involved with the tumour
What is M0 in pancreatic cancer?
Tumour has not spread to distant lymph nodes (other than those near the pancreas, or to distant organs such as the liver, lungs, or brain
What is M1 in pancreatic cancer?
Distant metastases are present
What proportion of patients present with pancreatic cancer so advanced that the only treatment options are palliative?
1/3
What are the palliative care approaches in advanced pancreatic cancer?
- Pain relief
- Symptom control
How can jaundice be managed in palliative care for pancreatic cancer?
Endoscopic stenting
How can duodenal obstruction be managed in palliative care for pancreatic cancer?
Surgical gastric bypass
How can pain be managed in palliative care for pancreatic cancer?
Coeliac plexus nerve block
What is the only treatment option that offers the possibility of long term remission for pancreatic cancer?
Surgery
What surgical procedures can be used in pancreatic cancer?
- Pancreaticoduodenectomy
- Total pancreatectomy
What is the problem with the surgical procedures used in pancreatic cancer?
They are major procedures with high complication rates and serious morbidity
What does surgical feasibility depend on in pancreatic cancer?
- Tumour size
- Tumour spread
- Overall performance status of the patient
What % of cases of pancreatic cancer reach the surgical feasibility criteria?
About 20%
Is a cure common in surgical intervention in pancreatic cancer?
No, it is an outcome for a small minority
What % of pancreatic cancer patients with radiologically operable tumours actually have surgically operable disease on laparotomy?
30%
What surgical procedures might those with more advanced pancreatic cancer be suitable for?
- Biliary stenting
- Bypass procedures
What are the potential complications of surgery for pancreatic cancer?
- Becoming diabetic
- Loosing pancreatic exocrine function
How is the loss of pancreatic exocrine function following surgery managed?
By the use of pancreatic enzymes
Who is radiotherapy most useful for in pancreatic cancer?
Those with locally advanced disease, for palliation of pain in particular
What is the radiation dose in pancreatic cancer?
High, 40-60Gy
What is the result of the radiation dose being high in pancreatic cancer?
Adverse effects may outweigh benefits
What might chemotherapy be used for in pancreatic cancer?
Pallitation
What chemotherapy agent is used in pancreatic cancer?
Gemcitabine
What kind of chemotherapy agent is gemcitabine?
A nucleoside analogue
What is the benefit of gemcitabine in pancreatic cancer?
It has been shown to improve symptoms and disease control
When can chemotherapy be administered in pancreatic cancer?
- Before or after surgery
- In advanced disease
- In combination with radiotherapy
What chemotherapy combination is used in pancreatic cancer?
FOLFIRINOX (5-FU, folinic acid, irinotecan, and oxaliplatin)
What is the advantage of FOLFIRINOX?
It has been shown in clinical trials to provide a better survival time in advanced pancreatic cancer than gemcitabine alone
What is the disadvantage of FOLFIRINOX?
It is considerably more toxic than gemcitabine alone
What affect have improvements in palliative care had on pancreatic cancer prognosis?
They have lead to a modest increase in short term survival of pancreatic cancer
What is the median survival of patients with locally advanced or metastatic pancreatic cancer?
3-4 months
What is the median survival for those who have had surgical resection of pancreatic cancer?
11-20 months
What is the 1 year survival of pancreatic cancer?
16%
What is the 5 year survival of pancreatic cancer?
About 3%
Which pancreatic cancer patients have a better prognosis?
Those diagnosed early with periampullary cancer, with a 5 year survival of up to 50%
