Pancreatic cancer

Question 1

Symptoms:

Answer 1

Dull epigastric pain radiating to middle back (esp body and tail)
Weight loss
Painless jaundice, pale stool, dark urine
Itching
Nausea/indigestion
Change in bowel habit - fatty stool (steatorrhoea)
Recent onset diabetes
Blood clots - DVT

Question 2

Symptoms of obstructive jaundice?

Answer 2

Itchy deposits in skin
Bleeding on skin
No sleep
Pale stool and dark urine

Question 3

Differentials between hepatitis and obstructive jaundice?

Answer 3

Alanine transferase and aspartate transferase levels are high in hepatitis and low in obstructive jaundice
Alkaline phosphatase level is high in obstructive jaundice and low in hepatitis
U/S of the liver - dilated biliary trees indicates obstruction, normal indicates hepatitis or drugs

Question 4

Exam: Courvoisier’s law

Answer 4

Palpably enlarged gall bladder which is non tender with mild-painless jaundice then the cause is unlikely to be gallstones

Question 5

Investigations:

Answer 5

FBC, U+Es, LFTs, CEA
CA 19-9 (monoclonal Ab tumour marker)
CT (staging) - hypodense mass with fibrosis and adhesion

Question 6

When is the tumour not resectable?

Answer 6

If it has spread to important vessels near the pancreas e.g. hepatic portal vein or hepatic artery

Question 7

Stage 1 =

Answer 7

Localised, <2cm
a <0.5cm
b 0.5-1cm
c 1-2cm

Question 8

Stage 2 =

Answer 8

2-4cm

Question 9

Stage 3 =

Answer 9

> 4cm

Question 10

Stage 4 =

Answer 10

The cancer has grown outside the pancreas and into one of the blood vessels

Question 11

N staging:

Answer 11

N0 = no LN spread
N1 = 1-3 LNs
N2 >4 LNs (likely to have spread outside of the pancreas)

Question 12

What makes a pancreatic tumour resectable?

Answer 12

<3cm

Nearer head with no LN spread

Question 13

What is a pyloric preserving pancreatoduodenectomy (PPPD)?

Answer 13

Pyloris is preserved
Remove gallbladder, duodenum and 1/3 of whole pancreas (from the head end)
Attach remaining pancreas to the small bowel

Question 14

What is Whipple’s procedure?

Answer 14

Preserve the tail of the pancreas

Resect the pylori, gallbladder, duodenum and 1/3 of whole pancreas (from the head end)

Question 15

What is a total pancreatomy?

Answer 15

Remove whole pancreas, gallbladder, pylori and duodenum

Question 16

How are pancreatic cancers graded?

Answer 16

Low grade have normal cells
High grade (G3/4) have abnormal cells and rapid growth

Question 17

Different types of pancreatic cancers?

Answer 17

> 80% are exocrine ductal adenocarcinomas
Cystic tumours, most benign, better prognosis
Acinar cells, younger than adenocarcinomas, slower growing, better prognosis
PNETs

Question 18

What are PNETs?

Answer 18

Pancreatic neuroendocrine tumours
Most are malignant
1/3 produce hormones and 2/3 are non-functioning
Better prognosis than adenocarcinomas

Question 19

Types of PNET:

Answer 19

Gastrinomas
Insulinomas
Somatostatinomas
VIPomas
Glucagonomas

Question 20

Well differentiated NET:

Answer 20

Low/intermediate grade tumours <20 mitoses

Ki-67 index <20%

Question 21

Poorly differentiated NET:

Answer 21

High grade tumours >20 mitoses

Ki-67 index >20%

Question 22

Signs of pancreatic cancer:

Answer 22

Loss of exocrine function e.g. steatorrhoea
Loss of endocrine function e.g. diabetes
Atypical back pain
Migratory thrombophlebitis (Trosseau's sign)

Question 23

Risk factors:

Answer 23

Lynch syndrome
BRCA2
Smoking
Diabetes
Chronic pancreatitis
Multipler endocrine neoplasia