Pancreatic cancer (GI) Flashcards
What does pancreatic cancer refer to?
Primary pancreatic ductal adenocarcinoma - most common form which accounts for >90%
Which demographic is pancreatic cancer most common in?
65-75 years of age
Where are most pancreatic cancers found?
Most within head of pancreas > body > tail > multifocal
Where are pancreatic cancer distant metastases found? (4)
- liver
- lung
- skin
- brain
Describe the course of pancreatic cancer.
Linear progression model from pre-invasive pancreatic intraepithelial lesions to invasive ductal adenocarcinoma
Distinct precursor lesions are:
- pancreatic intraepithelial neoplasia (PanIN)
- intraductal papillary mucinous neoplasm
- mucinous cystic neoplasm
What are some risk factors for pancreatic cancer? (8)
- smoking
- high alcohol consumption
- family history
- chronic pancreatitis
- T2DM
- obesity
- diet - high in red meat / low folate
- inherited genetic syndromes:
- Peutz-Jeghers syndrome
- hereditary breast and ovarian cancer syndrome
- hereditary ovarian cancer syndrome
- Lynch syndrome
What is the most common presentation of pancreatic cancer?
65-75 years of age with painless obstructive jaundice and weight loss
Generally presents late with advanced disease
What are the clinical features of pancreatic cancer? (7)
- painless jaundice (due to biliary obstruction)
- non-specific upper abdominal pain or discomfort (–> back, worse when flat, RUQ if head of pancreas cancer)
- back pain (persistent = retroperitoneal metastases)
- weight loss and anorexia (advanced sign)
- steatorrhoea - greasy loose stools (extensive pancreatic infiltration/obstruction of major ducts –> exocrine dysfunction)
- pale stools (reduced stercobilinogen) + dark urine (reduced urobilinogen + increased conjugated BR) - cancer at head of pancreas obstructs bile flow
- pruritus (due to bile salts in circulation)
What might you find on examination in pancreatic cancer? (4+3)
- Courvoisier’s sign positive - painless palpable gallbladder and jaundice (more likely to be head of pancreas)
- Trousseau’s sign of malignancy - migratory thrombophlebitis due to increased risk of thromboembolic disease in pancreatic cancer
- signs of DIC - petechiae, purpura, bruising
- palpable abdominal masses:
- hepatomegaly - due to metastases
- gallbladder - Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable GB is unlikely to be due to gallstones
- epigastric mass - primary tumour
What is Courvoisier’s law in pancreatic cancer?
In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones (most likely to be pancreatic cancer)
What is a sign of exocrine and endocrine dysfunction in pancreatic cancer?
- exocrine dysfunction - steatorrhoea
- endocrine dysfunction - new onset DM
What are the first-line investigations for pancreatic cancer? (3)
- pancreatic protocol CT
- abdominal ultrasound
- LFTs
What is the first-line investigation of choice for pancreatic cancer?
High resolution pancreas-specific CT - to show mass in pancreas –> diagnose, stage and determine if treatable
Ix of choice
What sign do we look for in CT pancreas in pancreatic cancer?
Double duct sign - dilatation of both pancreatic and common bile ducts
What investigation do we do in suspected pancreatic cancer if CT not available?
Abdominal ultrasound - detects pancreatic mass, dilated bile ducts and liver metastases
What would LFTs show in pancreatic cancer?
Demonstrates degree of obstructive jaundice:
- BR elevated
- ALP elevated
- GGT elevated
- ALT normal/slightly elevated
Vs in hepatocellular condition, ALT and AST will be raised
What biomarker do we look for in pancreatic cancer?
CA19-9 (preoperative staging, identifying recurrence and assessing response to Rx)
False positives in benign obstructive jaundice or chronic pancreatitis
What are some differential diagnoses for pancreatic cancer? (5)
- chronic pancreatitis (pain–>back, malabsorption, malnutrition, pancreatic endocrine insufficiency, alcohol Hx)
- bile duct stones
- ampullary carcinoma (IDA before obstructive jaundice, waxing and waning)
- cholangiocarcinoma (low bile duct cancers indistinguishable on presentation)
- autoimmune pancreatitis
What is the main surgical intervention for resectable pancreatic cancer?
Whipple’s resection (pancreaticoduodenectomy) - performed for resectable lesions at head of pancreas
What are some side effects of Whipple’s resection for pancreatic cancer? (2)
- dumping syndrome - food moves from stomach to small intestine too quickly –> cramps and diarrhoea
- peptic ulcer disease - acid eats at inner surface of stomach or small intestine
What is usually given after Whipple’s resection for pancreatic cancer?
Adjuvant chemotherapy
How is resectable pancreatic cancer managed?
- Whipple’s resection (pancreaticoduodenectomy)
- pancreatic enzyme replacement (pancreatin) +/- olanzapine
- if Sx of cholangitis - preoperative biliary stenting
- if metastatic disease - neoadjuvant radiotherapy/chemotherapy
- adjuvant chemotherapy post-surgery
What do we give for palliation in pancreatic cancer?
ERCP with stenting
How do we manage locally advanced unresectable (stage 3) / metastatic (stage 4) pancreatic cancer?
- ERCP with stenting
- chemotherapy / chemoradiotherapy / stereotactic body radiotherapy / immunotherapy
- pain management + pancreatic enzyme replacement (pancreatin) +/- olanzapine
What are some complications of pancreatic cancer? (5)
- surgical complications - pancreatic leaks & fistula
- duodenal obstruction
- cholangitis
- DVT & PE (LMWH preferred over warfarin long term)
- bleeding (tumour ulcerated into duodenum)
Describe the prognosis of pancreatic cancer.
- very aggressive cancer with poor prognosis as they tend to present late
- overall 5-year survival rate is 10% (2% with metastatic disease)
- patients with metastatic disease (55%) have a limited survival of 3-6m
- only 5-10% can undergo potentially curative surgery
