Pancreatic cancer Flashcards
Symptoms:
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
Symptoms of obstructive jaundice?
Itchy deposits in skin
Bleeding on skin
No sleep
Pale stool and dark urine
Differentials between hepatitis and obstructive jaundice?
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
Exam: Courvoisier’s law
Palpably enlarged gall bladder which is non tender with mild-painless jaundice then the cause is unlikely to be gallstones
Investigations:
FBC, U+Es, LFTs, CEA
CA 19-9 (monoclonal Ab tumour marker)
CT (staging) - hypodense mass with fibrosis and adhesion
When is the tumour not resectable?
If it has spread to important vessels near the pancreas e.g. hepatic portal vein or hepatic artery
Stage 1 =
Localised, <2cm
a <0.5cm
b 0.5-1cm
c 1-2cm
Stage 2 =
2-4cm
Stage 3 =
> 4cm
Stage 4 =
The cancer has grown outside the pancreas and into one of the blood vessels
N staging:
N0 = no LN spread
N1 = 1-3 LNs
N2 >4 LNs (likely to have spread outside of the pancreas)
What makes a pancreatic tumour resectable?
<3cm
Nearer head with no LN spread
What is a pyloric preserving pancreatoduodenectomy (PPPD)?
Pyloris is preserved
Remove gallbladder, duodenum and 1/3 of whole pancreas (from the head end)
Attach remaining pancreas to the small bowel
What is Whipple’s procedure?
Preserve the tail of the pancreas
Resect the pylori, gallbladder, duodenum and 1/3 of whole pancreas (from the head end)
What is a total pancreatomy?
Remove whole pancreas, gallbladder, pylori and duodenum
How are pancreatic cancers graded?
Low grade have normal cells High grade (G3/4) have abnormal cells and rapid growth
Different types of pancreatic cancers?
> 80% are exocrine ductal adenocarcinomas
Cystic tumours, most benign, better prognosis
Acinar cells, younger than adenocarcinomas, slower growing, better prognosis
PNETs
What are PNETs?
Pancreatic neuroendocrine tumours
Most are malignant
1/3 produce hormones and 2/3 are non-functioning
Better prognosis than adenocarcinomas
Types of PNET:
Gastrinomas Insulinomas Somatostatinomas VIPomas Glucagonomas
Well differentiated NET:
Low/intermediate grade tumours <20 mitoses
Ki-67 index <20%
Poorly differentiated NET:
High grade tumours >20 mitoses
Ki-67 index >20%
Signs of pancreatic cancer:
Loss of exocrine function e.g. steatorrhoea Loss of endocrine function e.g. diabetes Atypical back pain Migratory thrombophlebitis (Trosseau's sign)
Risk factors:
Lynch syndrome BRCA2 Smoking Diabetes Chronic pancreatitis Multipler endocrine neoplasia
