pancreatic cancer Flashcards
what type of pancreatic cancers are there?
- ductal carcinomas of the pancreas (90%)
- exocrine tumours e.g pancreatic cystic carcinoma
- endocrine tumours from islet cells
what are group usually experiences pancreatic cancer?
60-80 years old
whats the mortality rate like?
high, with diagnosis usually too late for curative treatment
what local structures are usually involved as the cancer spreads?
direct invasion involves
- spleen
- transverse colon
- adrenal glands
lymphatic metasteses involves
- regional lymph nodes
- liver
- lungs
- peritoneum
metastasis is common at the time of diagnosis
what are the risk factors for pancreatic cancer?
- smoking
- chronic pancreatitis
- family history
- late onset diabetes mellitus
how does pancreatic cancer present?
most cases of pancreatic carcinoma are unresectable at diagnosis, a testament to the late, vague and non specific signs
specific clinical features can depend on the site of tumour
head of the pancreas can present with
- obstructive jaundice (compression of common bile duct)
- abdominal pain radiating to the back due to invasion of coeliac plexus or 2ndry to pancreatitis
- weight loss due to metabolic effects of cancer, or 2ndry to endocrine dysfunction
- acute pancreatitis
- thrombophlebitis migrant
Tumours of the tail of the pancreas have an insidious course and are often not symptomatic till a late stage
on examination
- cachectic
- malnourished
- jaundiced
- abdominal mass in epigastric region
- enlarged gall bladder
what are your differentials for causes of obstructive jaundice?
- gallstone disease
- cholangiocarcinoma
- benign gallbladder stricture
what are your differentials for causes of epigastric abdominal pain?
- gallstones
- peptic ulcer disease
- gastric carcinoma
- acute coronary syndrome
what laboratory tests can be done to investigate pancreatic cancer?
initial blood tests including
- FBC ( anaemia or thrombocytopenia)
- LFTs (raised bilirubin, alkaline phosphatase, gamma GT, showing obstructive jaundice picture)
- CA19-9 is a tumour marker with high sensitivity and specify for pancreatic cancer, however usually used for assessing response to treatment rather than initial diagnosis
what imaging can be done for pancreatic cancer?
- abdominal ultrasound may show pancreatic mass/ dilated biliary tree (or hepatic metastases/ascites if late stage
- CT imaging aids diagnosis and is prognostically informative as can stage disease progression
- chest abdomen pelvis CT once diagnosed for staging
- PET CT if localised disease on CT but will be having cancer treatment
- endoscopic ultrasound (EUS) can be used for fine needle aspiration biopsy to histologically evaluate lesion
- ERCP can be used to access lesion for biopsy or cytology if its in suitable location
what is the surgical management for pancreatic tumours?
- radial resection is the only curative option
- tumour of head of pancreas, commonly get a pancreaticoduodenectomy, aka a whiles procedure.
- tumours of body/tail, distal pancreatectomy can be performed
what are the contraindications for surgery?
peritoneal, liver and distant metasteses
what are the specfific complications of surgery?
pancreatic fistula
delayed gastric emptying
pancreatic insufficiency
when is chemotherapy recommended and what is used?
adjuvant chemotherapy is recommended after surgery
usually use 5-flourouracil
metastatic disease, use of the FLOFIRNOX regime of 4 medications is advised in those with a good performance status, but only has modest improvements in survival
gemcitabine therapy can be considered for those who aren’t well enough to tolerate FLOFIRINOX
what is used for palliative care?
majority of people will need palliative care
- insert biliary stent via ERCP or percutaneously to relieve obstructive jaundice and associated pruritis
- palliative chemo with a gemcitabine based regime in patients with good performance status
- exocrine insufficiency with associated malabsorption and steatorrhoea can be treated with enzyme replacements (including lipase) e.g creon