Pancreatic Cancer

Question 1

What age group are more likely to get pancreatic cancer?

Answer 1

> 40

Question 2

What are risk factors for pancreatic cancer?

Answer 2

1) Cigarette smoking
2) Diet rich in animal fats and protein
3) Obesity
Family history
4) Hereditary syndromes e.g. hereditary pancreatitis, Lynch syndrome, Peutz-Jeghers

Question 3

What are symptoms of pancreatic cancer?

Answer 3

1) Dull epigastric pain radiating to middle back
2) Obstructive jaundice (can be painless)
3) Weight loss
4) Sickness/indigestion
5) Change in bowel habit - steatorrhoea
6) Diabetes (recent onset)
7) Blood clots e.g. common cause of unexplained occult DVT - migratory thrombophlebitis (Trousseau sign)

Question 4

In which cancers in dull epigastric pain radiating to the middle back especially common?

Answer 4

Cancer in the body and tail of pancreas

Question 5

Why does pain occur in pancreatic cancer?

Answer 5

• The coeliac plexus is around the area of the body and tail of the pancreas
• So any involvement around that area will lead to very severe abdominal pain

Question 6

In what other condition to pts get coeliac plexus pain?

Answer 6

Chronic pancreatitis

Question 7

How can you relieve coeliac plexus pain?

Answer 7

Block the coeliac plexus by various injections into the plexus

Question 8

Which patients get obstructive jaundice?

Answer 8

In pts with cancer of the head of the pancreas

Question 9

What are symptoms of obstructive jaundice?

Answer 9

1) Pale stool
2) Dark urine
3) Severe itching (bad scratch marks)

Question 10

Why does steatorrhoea occur in pancreatic cancer?

Answer 10

Fatty diarrhoea bc don’t have pancreatic enzymes to digest fat

Question 11

What other types of cancer come under cancer of the head of the pancreas?

Answer 11

• Can be cancer of the bile duct as well e.g. cholangiocarcinoma bc the bile duct goes to the head of the pancreas as well
• Doesn’t always mean exocrine tumour of the pancreas

Question 12

Describe the entero-hepatic re circulation of bile

Answer 12

1) Urobilinogen is formed in the intestines by bacterial action on bilirubin (BR excreted during fatty meal)
2) Urobilinogen is reabsorbed back in the terminal ileum to the liver and converted into urobilin which is excreted by the kidney (yellow colour of urine)
3) The urobilinogen in the intestine is reduced to brown stercobilin and excreted in faeces (brown colour of faeces)

Question 13

What causes obstructive jaundice?

Answer 13

Biliary obstruction

• If there is a blockage to the biliary system e.g. common bile duct, bile cannot get excreted into the small bowel
• Therefore there will be no urobilinogen

Question 14

What are the consequences of biliary obstruction?

Answer 14

• Decreased conjugated bilirubin reaches the intestine for conversion to urobilinogen
• Decreased urobilin in urine
• Decreased stercobilin in faeces (pale stool)
• Increased conjugated bilirubin in blood bc it is instead excreted directly from the liver to the circulation (excreted in urine - dark urine)

Question 15

Describe LFTs in hepatitis

Answer 15

• High ALT and AST due to hepatocellular damage

- Low ALP

Question 16

Describe LFTs in obstructive jaundice

Answer 16

• Low ALT and AST

- High ALP

Question 17

What is the main investigation of obstructive jaundice?

Answer 17

Ultrasound scan of the liver and biliary system

Question 18

Why do you do an ultrasound scan in obstructive jaundice?

Answer 18

• Shows whether biliary trees are dilated
• If they are, obstruction either from the outside, within the wall (cholangiocarcinoma) or inside the lumen (gall stone)

Question 19

What are the differential diagnoses if there is biliary tree dilation on US?

Answer 19

• Surgical causes of obstructive jaundice

- Stones, tumours

Question 20

What are the differential diagnoses if there is no biliary tree dilation on US?

Answer 20

• Hepatocellular causes of obstructive jaundice

- Hepatitis, drug induced reaction

Question 21

What is Courvoisier’s law?

Answer 21

In the presence of a palpably enlarged gall bladder which is non-tender and there is mild painless jaundice the cause is unlikely to be gallstones

Question 22

Explain Courvoisier’s law

Answer 22

With gallstones, repeated infection causes fibrosis of the gall bladder, therefore it is not palpable

Question 23

What investigations would you do for pancreatic cancer?

Answer 23

Blood tests

• FBC, U&E, LFTs
• CA 19-9 (cancer antigen 19-9)

Question 24

What is the pancreatic tumour marker in blood?

Answer 24

CA 19-9

Question 25

What scan would you do to stage pancreatic cancer?

Answer 25

CT scan - shows size, position and spread of tumour

Question 26

What might you see on a CT scan with pancreatic cancer?

Answer 26

• Poorly defined hypodense mass

- Extensive surrounding desmoplastic reaction (fibrosis, adhesion)

Question 27

What is CA 19-9 a tumour marker for?

Answer 27

Pancreatic cancer

Question 28

What are the tumour stages of pancreatic cancer?

Answer 28

T1 - < 2cm
T2 - < 4cm
T3 - > 4cm
T4 - involves nearby large blood vessels or organs

Question 29

What scan would you do to plan treatment for pancreatic tumour?

Answer 29

CT

Question 30

What types of pancreatic cancers tend to be resectable?

Answer 30

• < 3cm
• Head of the pancreas cancer - tends to present at an early stage with jaundice (remove whole cancer + head of pancreas)

Question 31

What types of pancreatic cancers are less likely to be resectable?

Answer 31

• Cancer involving body or tail of the pancreas - tends to present late and more advanced
• Spread to nearby lymph nodes or major blood vessels - can’t really cut out a major blood vessel around that area

Question 32

What are the 3 types of surgery for pancreatic cancer?

Answer 32

1) Pyloric preserving pancreatoduodenectomy (PPPD)
2) Whipple’s procedure
3) Total pancreatectomy

Question 33

Are most pancreatic cancers exocrine or endocrine adenocarcinomas?

Answer 33

Exocrine adenocarcinomas - secrete digestive enzymes

Question 34

What are the 3 types of exocrine adenocarcinomas?

Answer 34

1) Ductal adenocarcinomas (> 80%)
2) Cystic tumours - most benign, better prognosis
3) Cancer of acinar cells (produce pancreatic juices at ends of ducts) - younger age, slower growing, better prognosis

Question 35

Describe a PPPD

Answer 35

• For cancer in the head of the pancreas
• Need to remove the whole duodenum bc of the pancreatic drainage to the duodenum
• Then reconnect everything to the jejunum
• Preserve the pylorus bc the pylorus regulates gastric emptying/discharge into the small bowel - better function if keep pylorus

Question 36

Describe Whipple’s procedure (pancreaticoduodenectomy)

Answer 36

• Performed for resectable lesions in the head of the pancreas
• Pylorus resected
• Join stomach directly onto jejunum
• Don’t have that more refined control of digestion

Question 37

Describe a total pancreatectomy

Answer 37

• Remove whole pancreas, duodenum, pylorus and gall bladder
• Join stomach to the jejunum
• Join bile duct directly to small bowel

Question 38

Describe pancreatic neuroendocrine tumours (PNETS) or islet cell tumours

Answer 38

• Named after hormone they produce e.g. gastrin, insulin, somatostatin, VIP, glucagon - strange symptoms
• ⅔ PNETS non-functioning - no hormone production, no symptoms
• Better prognosis than exocrine