Pancreatic Cancer Flashcards
Most common pancreatic cancer
Ductal carcinoma of the pancreas (90%)
What can the remaining cancers be divided into?
Exocrine tumours (pancreatic cystic carcinoma)
Endocrine tumours (from islet cells of pancreas)
Epidemiology
High mortality
Rare under 40 years of age
80% of cases occur between 60-80yrs
Rarely diagnosed early enough for curative treatment
Pathophysiology of ductal carcinoma
Direct invasion of local structures which involves the spleen ,transverse colon and adrenal glands
There is also lympathic metastasis in regional LN, liver, lungs and peritoneum
Metastasis is common at time of diagnosis
Risk factors
Smoking and chronic pancreatitis
Hereditary
Late onset DM (>50 years of age onset have 8x greater risk)
Specific clinical features
Obstructive jaundice that is painless
Weight loss due to metabolic effects or secondary to exocrine dysfunction
Abdo pain due to invasion of coeliac plexus or pancreatitis
Can also have presentation of acute pancreatitis or thrombophlebitis migrans
Examination findings
Cachexia
Malnourished
Jaundic
Abdo mass
Enlarged gallbladder as per Courvoisier’s law
What is Courvoisier’s law?
Presence of jaundice and an enlarged/palpable gallbladder should warrant suspicion of malignancy of the biliary tree or pancreas.
Dx
Causes of obstructive jaundice
Causes of epigastric abdo pain
Lab tests
Routine bloods with FBC, LFTs etc…
Serum amylase and clotting would be done as well
CA19-9 tumour marker as well
Lab test findings
Anaemia or thrombocytopenia
Raised bilirubin, ALP and GGT
CA19-9 is raised but better in assessing response to treatment rather than for intial diagnosis
Initial imaging
Abdo USS
Other imaging
CT imaging
CT chest,abdo,pelvis
PET CT
EUS with fine needle aspiration biopsy
ERCP
USS findings
Pancreatic mass or a dilated biliary tree
What is the most important investiation in terms of diagnosis
CT imaging
It is also the most prognostically informative imaging modality
What should be done after confirming diagnosis with CT?
CT abdo-pelvis-chest to check staging
PET-CT may be warranted as well.
EUS fine needle aspiration biopsy might be done if diagnosis is still unclear.
ERCP can be used to access the lesion for biopsy or cytology
What is the only curative management option of pancreatic cancer?
Radical resection
Approach for tumours of the head of the pancreas
Pancreaticduodenectomy (Whipple’s procedure)
Approach for patients with tumours of the body or tail of pancreas
Distal pancreatectomy
Absolute contraindications to surgery
Peritoneal, liver and distant metastases
Complications of radical resection
Pancreatic fistula
Delayed gastric emptying
Pancreatic insufficiency
Explain Whipple’s procedure
Removal of the head of the pancreas, the antrum of the stomach and the 1st and 2nd parts of the duodenum.
Also removal of the common bile duct and the gallbladder.
Tail of the pancreas and the hepatic duct are attached to the jejunum to allow bile and pancreatic juice to drain into the gut.
Stomach is the anastomosed with jejunum allowing for passage of food.
Why are all of those viscera removed?
Because they share a common arterial supply of the gastroduodenal artery with the head of the pancreas and the duodenum.
When is chemo used?
Adjuvant chemotherapy with 5-fluorouracil is recommended after surgery.
In metastatic disease FOLFIRINOX regime can be used in patients with good performance status
Palliative care of pancreatic cancer
Insertion of biliary stent via ERCP or percutaneously
Palliative chemotherapy that is gemcitabine-based
Exocrine insufficiency is common in advanced disease so enzyme replacement might be used.
Prognosis
5 year <5%
