Pancreatic Cancer

Question 1

Causes

Answer 1

Smoking

Chronic pancreatitis

High fat diet

Question 2

Types

Answer 2

Ductal adenocarcinoma (most common) in head

Neuroendocrine tumours and in tail

Question 3

Features

Answer 3

Head of pancreas cancer:
Non specific epigastric / upper abdominal / back pain
Malabsorption (pale stools and dark urine)
Painless jaundice
Unintentional weight loss
Steatorrhoea (greasy stools due to malabsorption due to lack of bile)
Palpable mass in epigastric region

Body / tail pancreas cancer:
Similar symptoms without obstructive jaundice

Question 4

Courvoisiers law

Answer 4

In the presence of painless jaundice, a palpable gallbladder will unlikely be gallstones

Because in gall stones the gall bladder tends to get small and fibrosed

Question 5

2 week wait indications

Answer 5

40 and over and jaundice

Over 60 and weight loss and:
Diarrhoea or constipation 
New onset diabetes 
Back or abdominal pain 
Vomiting

Question 6

Investigations

Answer 6

Bloods: obstructive LFTs, ca199

Imaging: USS, CT

Special ix: endoscopic ultrasound and biopsy taken

Question 7

Management

Answer 7

All cases must be discussed at HPB (hepatobiliary) MDT meeting to decide management

Medical: adjuvant and neoadjuvant chemotherapy

Surgical:
Whipples pancreaticoduodenectomy for head of the pancreas cancer
Distal pancreatectomy for tumour of body/tail of pancreas
Radiotherapy

Question 8

What is the whipples procedure?

When do you do it?

Modified?

Risks

Answer 8

Requires the patient the be in good baseline health

For tumour of head of pancreas with no spread

Involves removing head of pancreas, gallbladder, duodenum and pylorus

Modified Whipple’s involves leaving the pylorus, and has equal success rates to traditional Whipples

Risks: dumping syndrome

Question 9

Where does pancreas cancer normally metastasize to?

Answer 9

Typically metastasize early to liver, then to peritoneum, lungs and bones

Question 10

Associated paraneoplastic syndrome

Answer 10

Trousseau syndrome

The fact that migratory thrombophlebitis may occur in pancreatic cancer
(e.g. painful

Thrombophlebitis is a result of the release of procoagulants (e.g. tissue factor, mucin) from tumor and stromal cells.